Methods for treating ulcers in thalassemia syndrome with an ActRIIB polypeptide

ABSTRACT

The present disclosure provides compositions and methods for treating or preventing ulcers in subjects having low red blood cell levels and/or hemoglobin levels (e.g, anemia). In some embodiments, the compositions of the disclosure may be used to treat or prevent ulcers associated with anemia.

RELATED APPLICATIONS

This application claims the benefit of priority to U.S. ProvisionalApplication Ser. Nos. 62/012,109, filed Jun. 13, 2014, and 62/045,808,filed Sep. 4, 2014. The disclosures of each of the foregoingapplications are hereby incorporated in their entirety.

SEQUENCE LISTING

The instant application contains a Sequence Listing which has beensubmitted electronically in ASCII format and is hereby incorporated byreference in its entirety. Said ASCII copy, created on Oct. 26, 2015, isnamed PHPH079101₁₃ seq.txt and is 109,927 bytes in size.

BACKGROUND OF THE INVENTION

The mature red blood cell, or erythrocyte, is responsible for oxygentransport in the circulatory systems of vertebrates. Red blood cellscontain high concentrations of hemoglobin, a protein that binds tooxygen in the lungs at relatively high partial pressure of oxygen (pO₂)and delivers oxygen to areas of the body with a relatively low pO₂.

Mature red blood cells are produced from pluripotent hematopoietic stemcells in a process termed erythropoiesis. Postnatal erythropoiesisoccurs primarily in the bone marrow and in the red pulp of the spleen.The coordinated action of various signaling pathways controls thebalance of cell proliferation, differentiation, survival, and death.Under normal conditions, red blood cells are produced at a rate thatmaintains a constant red cell mass in the body, and production mayincrease or decrease in response to various stimuli, including increasedor decreased oxygen tension or tissue demand. The process oferythropoiesis begins with the formation of lineage committed precursorcells and proceeds through a series of distinct precursor cell types.The final stages of erythropoiesis occur as reticulocytes are releasedinto the bloodstream and lose their mitochondria and ribosomes whileassuming the morphology of mature red blood cell. An elevated level ofreticulocytes, or an elevated reticulocyte:erythrocyte ratio, in theblood is indicative of increased red blood cell production rates.

In general, anemia is a condition that develops when a subject's bloodlacks enough healthy red blood cells or less than the normal quantity ofhemoglobin. Anemia may also be diagnosed when there is decreasedoxygen-binding capacity of red blood cells, which may result from adeformity in one or more hemoglobin subunits. As human cells depend onoxygen for survival, anemia can result in a wide range of clinicalcomplications including, e.g., tissue damage. For example, it has beenreported that ulcers are the one of most common cutaneous manifestationof chronic anemia disorders, particularly in hemolytic anemias such assickle-cell disease and thalassemia. See, e.g., Keast et al. (2004)Ostomy Wound Manage., 50(10): 64-70; Trent et al. (2004) Adv Skin WoundCare, 17(8): 410-416; J. R. Eckman (1996) Hematol Oncol Clin North Am.,10(6): 1333-1344; and Rassi et al. (2008) Pediatric Annals 37(5):322-328. The underlying mechanism for ulcer formation in anemic patientshas not been completely defined. However, it is believed that multiplecomplications of anemia contribute to ulcer development including, forexample, ischemia, decreased nitric oxide bioavailability, vascularobstruction, thrombosis, and hypoxia. Id.

Ulcer healing in anemic patients is typically a slow process, and suchpatients are also at a high risk of recurrent ulceration. See, e.g.,Keast et al. (2004) Ostomy Wound Manage., 50(10): 64-70; Trent et al.(2004) Adv Skin Wound Care, 17(8): 410-416; J. R. Eckman (1996) HematolOncol Clin North Am., 10(6): 1333-1344; and Rassi et al. (2008)Pediatric Annals 37(5): 322-328. Furthermore, most therapies have hadlimited success in the treatment of ulcers occurring in anemic patients.

Thus, it is an object of the present disclosure to provide alternativemethods for treating or preventing ulcers associated with anemia.

SUMMARY OF THE INVENTION

In part, the present disclosure demonstrates that ActRII antagonists canbe used to alter various blood parameters (e.g., red blood cell levels,hemoglobin levels, iron levels, bilirubin levels, nitrogen levels, etc.)in patients that have anemia as well as treat complications associatedwith anemia including, for example, ulcers. In particular, thedisclosure demonstrates that administration of a GDF Trap polypeptide,which is soluble form of an ActRIIB polypeptide having an acidic aminoacid at position 79 with respect to instant SEQ ID NO: 1, increases redblood cell levels and/or hemoglobin levels in patients having varioustypes of hemolytic anemia, particularly the hemoglobinopathic anemias,thalassemia and sickle-cell disease. Surprisingly, in addition todirectly affecting various red blood cell parameters, the disclosedActRII antagonist ameliorates other complications associated withanemia. For example, treatment with a GDF Trap protein was shown toincrease hemoglobin levels and promote wound healing of a cutaneous(skin) ulcer in a human patient having thalassemia. In some instances,amelioration of these associated complications is of equal or greaterimportance to patient health and quality of life as the treatment of theunderlying anemia. Therefore, in certain embodiments, the disclosureprovides methods of using one or more ActRII antagonists to increase redblood cell levels and/or hemoglobin levels in patients in need thereofand to treat or prevent one or more complications associated with lowred blood cell levels and/or hemoglobin levels in these patients. Inparticular, the disclosure provides methods for treating or preventingan ulcer, particularly a cutaneous ulcer, in a subject in need thereofthat has low levels of red blood cells and/or hemoglobin or is otherwiseclassified as a subject having an anemia [e.g., hereditaryspherocytosis, hereditary elliptocytosis, hereditary stomacytosis,glucose6-phosphate dehydrogenase deficiency, sickle-cell disease,thalassemia (both alpha and beta), and paroxysmal nocturnalhemoglobinuria] by administering one or more ActRII antagonists. In someembodiments, the disclosure provides methods for treating an ulcer,particularly a cutaneous ulcer, in a subject in need thereof that haslow levels of red blood cells and/or hemoglobin or is otherwiseclassified as a subject having an anemia [e.g., hereditaryspherocytosis, hereditary elliptocytosis, hereditary stomacytosis,glucose6-phosphate dehydrogenase deficiency, sickle-cell disease,thalassemia (both alpha and beta), and paroxysmal nocturnalhemoglobinuria] by administering one or more ActRII antagonists. In someembodiments, the disclosure provides methods for preventing an ulcer,particularly a cutaneous ulcer, in a subject in need thereof that haslow levels of red blood cells and/or hemoglobin or is otherwiseclassified as a subject having an anemia [e.g., hereditaryspherocytosis, hereditary elliptocytosis, hereditary stomacytosis,glucose6-phosphate dehydrogenase deficiency, sickle-cell disease,thalassemia (both alpha and beta), and paroxysmal nocturnalhemoglobinuria] by administering one or more ActRII antagonists. In someembodiments, the methods of the disclosure relate to treating orpreventing an ulcer, particularly a cutaneous ulcer, in a subject thathas a hemolytic anemia by administering one or more ActRII antagonists.In some embodiments, the methods of the disclosure relate to treating anulcer, particularly a cutaneous ulcer, in a subject that has a hemolyticanemia by administering one or more ActRII antagonists. In someembodiments, the methods of the disclosure relate to preventing anulcer, particularly a cutaneous ulcer, in a subject that has a hemolyticanemia by administering one or more ActRII antagonists. In particular,the methods of the disclosure relate, in part, to methods of treating orpreventing an ulcer, particularly a cutaneous ulcer, in a subject thathas a hemoglobinopathy anemia by administering one or more ActRIIantagonists. In some embodiments, the methods of the disclosure relateto methods of treating an ulcer, particularly a cutaneous ulcer, in asubject that has a hemoglobinopathy anemia by administering one or moreActRII antagonists. In some embodiments, the methods of the disclosurerelate to methods of preventing an ulcer, particularly a cutaneousulcer, in a subject that has a hemoglobinopathy anemia by administeringone or more ActRII antagonists. For example, the present disclosurerelates, in part, to methods of treating or preventing an ulcer,particularly a cutaneous ulcer, in a subject that has a thalassemiasyndrome by administering one or more ActRII antagonists. In someembodiments, the present disclosure relates to methods of treating anulcer, particularly a cutaneous ulcer, in a subject that has athalassemia syndrome by administering one or more ActRII antagonists. Insome embodiments, the present disclosure relates to methods ofpreventing an ulcer, particularly a cutaneous ulcer, in a subject thathas a thalassemia syndrome by administering one or more ActRIIantagonists. In some embodiments, the present disclosure relates tomethods of treating or preventing an ulcer, particularly a cutaneousulcer, in a subject that has sickle-cell disease by administering one ormore ActRII antagonists. In some embodiments, the present disclosurerelates to methods of treating an ulcer, particularly a cutaneous ulcer,in a subject that has sickle-cell disease by administering one or moreActRII antagonists. In some embodiments, the present disclosure relatesto methods of preventing an ulcer, particularly a cutaneous ulcer, in asubject that has sickle-cell disease by administering one or more ActRIIantagonists. In certain aspects, one or more ActRII antagonists can beused in combination with one or more existing supportive therapies fortreating or preventing ulcers and/or treating anemia (e.g., supportivetherapies for treating sickle-cell disease, thalassemia, etc.). Examplesof such supportive therapies are well known in the art and alsodescribed herein. In some embodiments, the subject is a transfusiondependent subject having anemia. In some embodiments, the subject is anon-transfusion dependent subject having anemia.

In part, the disclosure provides methods of treating ulcers associatedwith anemia, particularly treating or preventing cutaneous (skin)ulcers, with one or more ActRII antagonists. In some embodiments, thedisclosure provides methods of treating ulcers associated with anemia,particularly treating cutaneous (skin) ulcers, with one or more ActRIIantagonists. In part, the disclosure provides methods of preventingulcers associated with anemia, particularly preventing cutaneous (skin)ulcers, with one or more ActRII antagonists. ActRII antagonists of thedisclosure include, for example, agents that can inhibit ActRII receptor(e.g., an ActRIIA and/or ActRIIB receptor) mediated activation of asignal transduction pathway (e.g., activation of signal transduction viaintracellular mediators, such as SMAD 1, 2, 3, 5, and/or 8); agents thatcan inhibit one or more ActRII ligands (e.g., activin A, activin B,activin AB, activin C, activin E, GDF11, GDF8, BMP6, BMP7. Nodal, etc.)from, e.g., binding to and/or activating an ActRII receptor; agents thatinhibit expression (e.g., transcription, translation, cellularsecretion, or combinations thereof) of an ActRII ligand and/or an ActRIIreceptor; and agents that can inhibit one or more intracellularmediators of the ActRII signaling pathway (e.g., SMADs 1, 2, 3, 5,and/or 8).

In certain embodiments, the disclosure relates to one or more ActRIIantagonists for use in a method to increase red blood cell levels and/orhemoglobin levels in patients in need thereof and to treat or preventone or more complications associated with low red blood cell levelsand/or hemoglobin levels in these patients. In particular, thedisclosure provides ActRII antagonists for use in treating or preventingan ulcer, particularly a cutaneous ulcer, in a subject in need thereofthat has low levels of red blood cells and/or hemoglobin or is otherwiseclassified as a subject having an anemia [e.g., hereditaryspherocytosis, hereditary elliptocytosis, hereditary stomacytosis,glucose6-phosphate dehydrogenase deficiency, sickle-cell disease,thalassemia (both alpha and beta), and paroxysmal nocturnalhemoglobinuria]. In some embodiments, the disclosure provides ActRIIantagonists for use in treating an ulcer, particularly a cutaneousulcer, in a subject in need thereof that has low levels of red bloodcells and/or hemoglobin or is otherwise classified as a subject havingan anemia [e.g., hereditary spherocytosis, hereditary elliptocytosis,hereditary stomacytosis, glucose6-phosphate dehydrogenase deficiency,sickle-cell disease, thalassemia (both alpha and beta), and paroxysmalnocturnal hemoglobinuria]. In some embodiments, the disclosure providesActRII antagonists for use in preventing an ulcer, particularly acutaneous ulcer, in a subject in need thereof that has low levels of redblood cells and/or hemoglobin or is otherwise classified as a subjecthaving an anemia [e.g., hereditary spherocytosis, hereditaryelliptocytosis, hereditary stomacytosis, glucose6-phosphatedehydrogenase deficiency, sickle-cell disease, thalassemia (both alphaand beta), and paroxysmal nocturnal hemoglobinuria]. In someembodiments, the ActRII antagonists of the disclosure are for use intreating or preventing an ulcer, particularly a cutaneous ulcer, in asubject that has a hemolytic anemia. In some embodiments, the ActRIIantagonists of the disclosure are for use in treating an ulcer,particularly a cutaneous ulcer, in a subject that has a hemolyticanemia. In some embodiments, the ActRII antagonists of the disclosureare for use in preventing an ulcer, particularly a cutaneous ulcer, in asubject that has a hemolytic anemia. In particular, the ActRIIantagonists of the disclosure are for use in, in part, treating orpreventing an ulcer, particularly a cutaneous ulcer, in a subject thathas a hemoglobinopathy anemia. In some embodiments, the ActRIIantagonists of the disclosure are for use in treating an ulcer,particularly a cutaneous ulcer, in a subject that has a hemoglobinopathyanemia. In some embodiments, the ActRII antagonists of the disclosureare for use in preventing an ulcer, particularly a cutaneous ulcer, in asubject that has a hemoglobinopathy anemia. For example, the presentdisclosure relates, in part, to one or more ActRII antagonists for usein treating or preventing an ulcer, particularly a cutaneous ulcer, in asubject that has a thalassemia syndrome. In some embodiments, thepresent disclosure relates to one or more ActRII antagonists for use intreating an ulcer, particularly a cutaneous ulcer, in a subject that hasa thalassemia syndrome. In some embodiments, the present disclosurerelates to one or more ActRII antagonists for use in preventing anulcer, particularly a cutaneous ulcer, in a subject that has athalassemia syndrome. In some embodiments, the present disclosurerelates to one or more ActRII antagonists for use in treating orpreventing an ulcer, particularly a cutaneous ulcer, in a subject thathas sickle-cell disease. In some embodiments, the present disclosurerelates to one or more ActRII antagonists for use in treating an ulcer,particularly a cutaneous ulcer, in a subject that has sickle-celldisease. In some embodiments, the present disclosure relates to one ormore ActRII antagonists for use in preventing an ulcer, particularly acutaneous ulcer, in a subject that has sickle-cell disease. In certainaspects, one or more ActRII antagonists can be used in combination withone or more existing supportive therapies for treating or preventingulcers and/or treating anemia (e.g., supportive therapies for treatingsickle-cell disease, thalassemia, etc.). Examples of such supportivetherapies are well known in the art and also described herein.

In part, the disclosure provides one or more ActRII antagonists for usein treating ulcers associated with anemia, particularly treating orpreventing cutaneous (skin) ulcers. In some embodiments, the disclosureprovides one or more ActRII antagonists for use in treating ulcersassociated with anemia, particularly treating cutaneous (skin) ulcers,with one or more ActRII antagonists. In part, the disclosure providesone or more ActRII antagonists for use in preventing ulcers associatedwith anemia, particularly preventing cutaneous (skin) ulcers. ActRIIantagonists of the disclosure include, for example, agents that caninhibit ActRII receptor (e.g., an ActRIIA and/or ActRIIB receptor)mediated activation of a signal transduction pathway (e.g., activationof signal transduction via intracellular mediators, such as SMAD 1, 2,3, 5, and/or 8); agents that can inhibit one or more ActRII ligands(e.g., activin A, activin B, activin AB, activin C, activin E, GDF11,GDF8, BMP6, BMP7, Nodal, etc.) from, e.g., binding to and/or activatingan ActRII receptor; agents that inhibit expression (e.g., transcription,translation, cellular secretion, or combinations thereof) of an ActRIIligand and/or an ActRII receptor; and agents that can inhibit one ormore intracellular mediators of the ActRII signaling pathway (e.g.,SMADs 1, 2, 3, 5, and/or 8).

In certain embodiments, the disclosure relates to the use of one or moreActRII antagonists in the manufacture of a medicament for increasing redblood cell levels and/or hemoglobin levels in patients in need thereofand for treating or preventing one or more complications associated withlow red blood cell levels and/or hemoglobin levels in these patients. Inparticular, the disclosure provides the use of one or more ActRIIantagonists in the manufacture of a medicament for treating orpreventing an ulcer, particularly a cutaneous ulcer, in a subject inneed thereof that has low levels of red blood cells and/or hemoglobin oris otherwise classified as a subject having an anemia [e.g., hereditaryspherocytosis, hereditary elliptocytosis, hereditary stomacytosis,glucose6-phosphate dehydrogenase deficiency, sickle-cell disease,thalassemia (both alpha and beta), and paroxysmal nocturnalhemoglobinuria]. In some embodiments, the disclosure provides the use ofone or more ActRII antagonists in the manufacture of a medicament fortreating an ulcer, particularly a cutaneous ulcer, in a subject in needthereof that has low levels of red blood cells and/or hemoglobin or isotherwise classified as a subject having an anemia [e.g., hereditaryspherocytosis, hereditary elliptocytosis, hereditary stomacytosis,glucose6-phosphate dehydrogenase deficiency, sickle-cell disease,thalassemia (both alpha and beta), and paroxysmal nocturnalhemoglobinuria]. In some embodiments, the disclosure provides the use ofone or more ActRII antagonists in the manufacture of a medicament forpreventing an ulcer, particularly a cutaneous ulcer, in a subject inneed thereof that has low levels of red blood cells and/or hemoglobin oris otherwise classified as a subject having an anemia [e.g., hereditaryspherocytosis, hereditary elliptocytosis, hereditary stomacytosis,glucose6-phosphate dehydrogenase deficiency, sickle-cell disease,thalassemia (both alpha and beta), and paroxysmal nocturnalhemoglobinuria]. In some embodiments, the disclosure provides the use ofone or more ActRII antagonists in the manufacture of a medicament fortreating or preventing an ulcer, particularly a cutaneous ulcer, in asubject that has a hemolytic anemia. In some embodiments, the disclosureprovides the use of one or more ActRII antagonists in the manufacture ofa medicament for treating an ulcer, particularly a cutaneous ulcer, in asubject that has a hemolytic anemia. In some embodiments, the disclosureprovides the use of one or more ActRII antagonists in the manufacture ofa medicament for preventing an ulcer, particularly a cutaneous ulcer, ina subject that has a hemolytic anemia. In particular, the disclosureprovides the use of one or more ActRII antagonists in the manufacture ofa medicament for, in part, treating or preventing an ulcer, particularlya cutaneous ulcer, in a subject that has a hemoglobinopathy anemia. Insome embodiments, the disclosure provides the use of one or more ActRIIantagonists in the manufacture of a medicament for treating an ulcer,particularly a cutaneous ulcer, in a subject that has a hemoglobinopathyanemia. In some embodiments, the disclosure provides the use of one ormore ActRII antagonists in the manufacture of a medicament forpreventing an ulcer, particularly a cutaneous ulcer, in a subject thathas a hemoglobinopathy anemia. For example, the present disclosurerelates, in part, to the use of one or more ActRII antagonists in themanufacture of a medicament for treating or preventing an ulcer,particularly a cutaneous ulcer, in a subject that has a thalassemiasyndrome. In some embodiments, the disclosure provides the use of one ormore ActRII antagonists in the manufacture of a medicament for treatingan ulcer, particularly a cutaneous ulcer, in a subject that has athalassemia syndrome by administering one or more ActRII antagonists. Insome embodiments, the disclosure provides the use of one or more ActRIIantagonists in the manufacture of a medicament for preventing an ulcer,particularly a cutaneous ulcer, in a subject that has a thalassemiasyndrome. In some embodiments, the disclosure provides the use of one ormore ActRII antagonists in the manufacture of a medicament for treatingor preventing an ulcer, particularly a cutaneous ulcer, in a subjectthat has sickle-cell disease. In some embodiments, the disclosureprovides the use of one or more ActRII antagonists in the manufacture ofa medicament for treating an ulcer, particularly a cutaneous ulcer, in asubject that has sickle-cell disease. In some embodiments, thedisclosure provides the use of one or more ActRII antagonists in themanufacture of a medicament for preventing an ulcer, particularly acutaneous ulcer, in a subject that has sickle-cell disease. In certainaspects, one or more ActRII antagonists can be used in combination withone or more existing supportive therapies for treating or preventingulcers and/or treating anemia (e.g., supportive therapies for treatingsickle-cell disease, thalassemia, etc.). Examples of such supportivetherapies are well known in the art and also described herein.

In part, the disclosure provides the use of one or more ActRIIantagonists in the manufacture of a medicament for treating ulcersassociated with anemia, particularly treating or preventing cutaneous(skin) ulcers. In some embodiments, the disclosure provides the use ofone or more ActRII antagonists in the manufacture of a medicament fortreating ulcers associated with anemia, particularly treating cutaneous(skin) ulcers, with one or more ActRII antagonists. In part, thedisclosure provides the use of one or more ActRII antagonists in themanufacture of a medicament for preventing ulcers associated withanemia, particularly preventing cutaneous (skin) ulcers. ActRIIantagonists of the disclosure include, for example, agents that caninhibit ActRII receptor (e.g., an ActRIIA and/or ActRIIB receptor)mediated activation of a signal transduction pathway (e.g., activationof signal transduction via intracellular mediators, such as SMAD 1, 2,3, 5, and/or 8); agents that can inhibit one or more ActRII ligands(e.g., activin A, activin B, activin AB, activin C, activin E, GDF11,GDF8, BMP6, BMP7, Nodal, etc.) from, e.g., binding to and/or activatingan ActRII receptor; agents that inhibit expression (e.g., transcription,translation, cellular secretion, or combinations thereof) of an ActRIIligand and/or an ActRII receptor; and agents that can inhibit one ormore intracellular mediators of the ActRII signaling pathway (e.g.,SMADs 1, 2, 3, 5, and/or 8).

In certain embodiments, ActRII antagonists to be used in accordance withthe methods disclosed herein are agents that bind to and/or inhibitGDF11 and/or GDF8 (e.g., an agent that inhibits GDF11- and/orGDF8-mediated activation of ActRIIA and/or ActRIIB signalingtransduction, such as SMAD 2/3 signaling). Such agents are referred tocollectively as GDF-ActRII antagonists. Optionally, such GDF-ActRIIantagonists may further inhibit one or more of activin A, activin B,activin AB, activin C, activin E, BMP6, BMP7, and Nodal. Therefore, insome embodiments, the disclosure provides methods of using one or moreActRII antagonists, including, for example, soluble ActRIIApolypeptides, soluble ActRIIB polypeptides, GDF Trap polypeptides,anti-ActRIIA antibodies, anti-ActRIIB antibodies, anti-ActRII ligandantibodies (e.g, anti-GDF11 antibodies, anti-GDF8 antibodies,anti-activin A antibodies, anti-activin B antibodies, anti-activin ABantibodies, anti-activin C antibodies, anti-activin E antibodies,anti-BMP6 antibodies, anti-BMP7 antibodies, and anti-Nodal antibodies),small molecule inhibitors of ActRIIA, small molecule inhibitors ofActRIIB, small molecule inhibitors of one or more ActRII ligands (e.g.,activin A, activin B, activin AB, activin C, activin E, GDF11, GDF8,BMP6, BMP7, Nodal, etc.), inhibitor nucleotides of ActRIIA, inhibitornucleotides of ActRIIB, inhibitor nucleotides of one or more ActRIIligands (e.g., activin A. activin B, activin AB, activin C, activin E,GDF11, GDF8, BMP6, BMP7, Nodal, etc.), or combinations thereof, toincrease red blood cell levels and/or hemoglobin levels in a subject inneed thereof, treat or prevent an anemia in a subject in need thereof,and/or treat or prevent ulcers, particularly cutaneous ulcers, in asubject that has anemia. In certain embodiments, ActRII antagonists tobe used in accordance with the methods disclosed herein bind activin Aor acitivin B. In certain embodiments, ActRII antagonists to be used inaccordance with the methods disclosed herein bind activin A. In certainembodiments, ActRII antagonists to be used in accordance with themethods disclosed herein bind activin B. In certain embodiments, ActRIIantagonists to be used in accordance with the methods disclosed hereindo not substantially bind to and/or inhibit activin A (e.g., activinA-mediated activation of ActRIIA and/or ActRIIB signaling transduction,such as SMAD 2/3 signaling).

In part, the present disclosure demonstrates that an ActRII antagonistcomprising a variant, extracellular (soluble) ActRIIB domain that bindsto and inhibits GDF11 activity (e.g., GDF11-mediated ActRIIA and/orActRIIB signaling transduction, such as SMAD 2/3 signaling) may be usedto increase red blood cell levels in vivo, treat anemia resulting fromvarious conditions/disorders, and treat a cutaneous ulcer in a patientwith anemia. Therefore, in certain embodiments, ActRII antagonists to beused in accordance with the methods disclosed herein [e.g., methods ofincreasing red blood cell levels in a subject in need thereof, methodsof treating anemia in a subject in need thereof, methods of treating orpreventing one or more complications of anemia (particularly ulcers) insubject in need thereof, etc.] are soluble ActRII polypeptides (e.g.,soluble ActRIIA or ActRIIB polypeptides) that bind to and/or inhibitGDF11 (e.g., GDF11-mediated activation of ActRIIA and/or ActRIIBsignaling transduction, such as SMAD 2/3 signaling). While solubleActRIIA and soluble ActRIIB ActRII antagonists may affect red blood cellformation and ulcers through a mechanism other than GDF11 antagonism,the disclosure nonetheless demonstrates that desirable therapeuticagents, with respect to the methods disclosed herein, may be selected onthe basis of GDF11 antagonism or ActRII antagonism or both. Optionally,such soluble ActRII polypeptide antagonists may further bind to and/orinhibit GDF8 (e.g. inhibit GDF8-mediated activation of ActRIIA and/orActRIIB signaling transduction, such as SMAD 2/3 signaling). In someembodiments, soluble ActRIIA and ActRIIB polypeptides of the disclosurethat bind to and/or inhibit GDF11 and/or GDF8 may further bind to and/orinhibit one or more additional ActRII ligands selected from: activin A,activin B, activin AB, activin C, activin E, BMP6, BMP7, and Nodal.

In certain aspects, the present disclosure provides GDF Traps that arevariant ActRII polypeptides (e.g., ActRIIA and ActRIIB polypeptides),including ActRII polypeptides having amino- and carboxy-terminaltruncations and/or other sequence alterations (one or more amino acidsubstitutions, additions, deletions, or combinations thereof).Optionally, GDF Traps of the invention may be designed to preferentiallyantagonize one or more ligands of ActRII receptors, such as GDF8 (alsocalled myostatin), GDF11, Nodal, BMP6, and BMP7 (also called OP-1). Asdisclosed herein, examples of GDF Traps include a set of variantsderived from ActRIIB that have greatly diminished affinity for activin,particularly activin A. These variants exhibit desirable effects on redblood cells while reducing effects on other tissues. Examples of suchvariants include those having an acidic amino acid [e.g., aspartic acid(D) or glutamic acid (E)] at the position corresponding to position 79of SEQ ID NO: 1. In certain embodiments, GDF Traps to be used inaccordance with the methods disclosed herein [e.g., methods ofincreasing red blood cell levels in a subject in need thereof, methodsof treating anemia in a subject in need thereof, methods of treating orpreventing one or more complications of anemia (particularly ulcers) insubject in need thereof, etc.] bind to and/or inhibit GDF11. Optionally,such GDF Traps may further bind to and/or inhibit GDF8. In someembodiments, GDF Traps that bind to and/or inhibit GDF11 and/or GDF8 mayfurther bind to and/or inhibit one or more additional ActRII ligands(e.g., activin B, activin E, BMP6, BMP7, and Nodal). In someembodiments, GDF Traps to be used in accordance with the methodsdisclosed herein do not substantially bind to and/or inhibit activin A(e.g., activin A-mediated activation of ActRIIA and/or ActRIIB signalingtransduction, such as SMAD 2/3 signaling). In certain embodiments, a GDFTrap polypeptide comprises an amino acid sequence that comprises,consists of, or consists essentially of, the amino acid sequence of SEQID NOs: 36, 37, 41, 44, 45, 50 or 51, and polypeptides that are at least80%, 85%, 90%, 95%, 96%, 97%, 98%, or 99% identical to any of theforegoing. In other embodiments, a GDF Trap polypeptide comprises anamino acid sequence that comprises, consists of, or consists essentiallyof the amino acid sequence of SEQ ID NOs: 2, 3, 4, 5, 6, 10, 11, 22, 26,28, 29, 31, or 49, and polypeptides that are at least 80%, 85%, 90%,95%, 96%, 97%, 98%, or 99% identical to any of the foregoing. In stillother embodiments, a GDF Trap polypeptide comprises an amino acidsequence that comprises of the amino acid sequence of SEQ ID NOs: 2, 3,4, 5, 6, 29, 31, or 49, and polypeptides that are at least 80%, 85%,90%, 95%, 96%, 97%, 98%, or 99% identical to any of the foregoing,wherein the position corresponding to 79 in SEQ ID NO: 1, 4, or 50 is anacidic amino acid. A GDF Trap may include a functional fragment of anatural ActRII polypeptide, such as one comprising at least 10, 20, or30 amino acids of a sequence selected from SEQ ID NOs: 1, 2, 3, 4, 5, 6,9, 10, 11, or 49 or a sequence of SEQ ID NO: 2, 5, 10, 11, or 49 lackingthe C-terminal 1, 2, 3, 4, 5 or 10 to 15 amino acids and lacking 1, 2,3, 4 or 5 amino acids at the N-terminus. In some embodiments, apolypeptide will comprise a truncation relative to SEQ ID NO: 2 or 5 ofbetween 2 and 5 amino acids at the N-terminus and no more than 3 aminoacids at the C-terminus. In some embodiments, a GDF Trap for use inaccordance with the methods disclosed herein consists of, or consistsessentially of, the amino acid sequence of SEQ ID NO:36.

Optionally, a GDF Trap comprising an altered ActRII ligand-bindingdomain has a ratio of K_(d) for activin A binding to K_(d) for GDF11and/or GDF8 binding that is at least 2-, 5-, 10-, 20, 50-, 100- or even1000-fold greater relative to the ratio for the wild-type ligand-bindingdomain. Optionally, the GDF Trap comprising an altered ligand-bindingdomain has a ratio of IC₅₀ for inhibiting activin A to IC₅₀ forinhibiting GDF11 and/or GDF8 that is at least 2-, 5-, 10-, 20-, 25-50-,100- or even 1000-fold greater relative to the wild-type ActRIIligand-binding domain. Optionally, the GDF Trap comprising an alteredligand-binding domain inhibits GDF11 and/or GDF8 with an IC₅₀ at least2, 5, 10, 20, 50, or even 100 times less than the IC₅₀ for inhibitingactivin A. These GDF Traps can be fusion proteins that include animmunoglobulin Fe domain (either wild-type or mutant). In certain cases,the subject soluble GDF Traps are antagonists (inhibitors) of GDF8and/or GDF11.

In certain aspects, the disclosure provides GDF Traps which are solubleActRIIB polypeptides comprising an altered ligand-binding (e.g.,GDF11-binding) domain. GDF Traps with altered ligand-binding domains maycomprise, for example, one or more mutations at amino acid residues suchas E37, E39, R40, K55, R56, Y60, A64, K74, W78, L79, D80, F82 and F101of human ActRIIB (numbering is relative to SEQ ID NO: 1). Optionally,the altered ligand-binding domain can have increased selectivity for aligand such as GDF8/GDF11 relative to a wild-type ligand-binding domainof an ActRIIB receptor. To illustrate, these mutations are demonstratedherein to increase the selectivity of the altered ligand-binding domainfor GDF11 (and therefore, presumably, GDF8) over activin: K74Y, K74F,K741, L79D, L79E, and D80I. The following mutations have the reverseeffect, increasing the ratio of activin binding over GDF11: D54A, K55A,L79A and F82A. The overall (GDF11 and activin) binding activity can beincreased by inclusion of the “tail” region or, presumably, anunstructured linker region, and also by use of a K74A mutation. Othermutations that caused an overall decrease in ligand binding affinityinclude: R40A, E37A, R56A, W78A, D80K, D80R, D80A, D80G, D80F, D80M andD80N. Mutations may be combined to achieve desired effects. For example,many of the mutations that affect the ratio of GDF11:Activin bindinghave an overall negative effect on ligand binding, and therefore, thesemay be combined with mutations that generally increase ligand binding toproduce an improved binding protein with ligand selectivity. In anexemplary embodiment, a GDF Trap is an ActRIIB polypeptide comprising anL79D or L79E mutation, optionally in combination with additional aminoacid substitutions, additions or deletions.

In certain embodiments, ActRII antagonists to be used in accordance withthe methods disclosed herein are ActRIIB polypeptides or ActRIIB-basedGDF Trap polypeptides. In general such ActRIIB polypeptides andActRIIB-based GDF Trap polypeptides are soluble polypeptides thatcomprise a portion/domain derived from the ActRIIB sequence of SEQ IDNO:1, 4, or 49, particularly an extracellular, ligand-bindingportion/domain derived from the ActRIIB sequence of SEQ ID NO:1, 4, or49. In some embodiments, the portion derived from ActRIIB corresponds toa sequence beginning at any one of amino acids 21-29 (e.g., 21, 22, 23,24, 25, 26, 27, 28, or 29) of SEQ ID NO:1 or 4 [optionally beginning at22-25 (e.g., 22, 23, 24, or 25) of SEQ ID NO:1 or 4] and ending at anyone of amino acids 109-134 (e.g., 109, 110, 111, 112, 113, 114, 115,116, 117, 118, 119, 120, 121, 122, 123, 124, 125, 126, 127, 128, 129,130, 131, 132, 133, or 134) of SEQ ID NO: 1 or 4. In some embodiments,the portion derived from ActRIIB corresponds to a sequence beginning atany one of amino acids 20-29 (e.g., 20, 21, 22, 23, 24, 25, 26, 27, 28,or 29) of SEQ ID NO: 1 or 4 [optionally beginning at 22-25 (e.g., 22,23, 24, or 25) of SEQ ID NO:1 or 4] and ending at any one of amino acids109-133 (e.g., 109, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119,120, 121, 122, 123, 124, 125, 126, 127, 128, 129, 130, 131, 132, or 133)of SEQ ID NO: 1 or 4. In some embodiments, the portion derived fromActRIIB corresponds to a sequence beginning at any one of amino acids20-24 (e.g., 20, 21, 22, 23, or 24) of SEQ ID NO: 1 or 4 [optionallybeginning at 22-25 (e.g., 22, 23, 24, or 25) of SEQ ID NO:1 or 4] andending at any one of amino acids 109-133 (e.g., 109, 110, 111, 112, 113,114, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124, 125, 126, 127,128, 129, 130, 131, 132, or 133) of SEQ ID NO: 1 or 4. In someembodiments, the portion derived from ActRIIB corresponds to a sequencebeginning at any one of amino acids 21-24 (e.g., 21, 22, 23, or 24) ofSEQ ID NO: 1 or 4 and ending at any of amino acids 109-134 (e.g., 109,110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, 121, 122, 123,124, 125, 126, 127, 128, 129, 130, 131, 132, 133, or 134) of SEQ ID NO:1 or 4. In some embodiments, the portion derived from ActRIIBcorresponds to a sequence beginning at any one of amino acids 20-24(e.g., 20, 21, 22, 23, or 24) of SEQ ID NO: 1 or 4 and ending at any oneof amino acids 118-133 (e.g., 118, 119, 120, 121, 122, 123, 124, 125,126, 127, 128, 129, 130, 131, 132. or 133) of SEQ ID NO: 1 or 4. In someembodiments, the portion derived from ActRIIB corresponds to a sequencebeginning at any one of amino acids 21-24 (e.g., 21, 22, 23. or 24) ofSEQ ID NO: 1 or 4 and ending at any one of amino acids 118-134 (e.g.,118, 119, 120, 121, 122, 123, 124, 125, 126, 127, 128, 129, 130, 131,132, 133, or 134) of SEQ ID NO: 1 or 4. In some embodiments, the portionderived from ActRIIB corresponds to a sequence beginning at any one ofamino acids 20-24 (e.g., 20, 21, 22, 23, or 24) of SEQ ID NO: 1 or 4 andending at any one of amino acids 128-133 (e.g., 128, 129, 130, 131, 132,or 133) of SEQ ID NO: 1 or 4. In some embodiments, the portion derivedfrom ActRIIB corresponds to a sequence beginning at any of amino acids20-24 (e.g., 20, 21, 22, 23, or 24) of SEQ ID NO: 1 or 39 and ending atany of amino acids 128-133 (e.g., 128, 129, 130, 131, 132, or 133) ofSEQ ID NO: 1 or 39. In some embodiments, the portion derived fromActRIIB corresponds to a sequence beginning at any one of amino acids21-29 (e.g., 21, 22, 23, 24, 25, 26, 27, 28, or 29) of SEQ ID NO: 1 or 4and ending at any one of amino acids 118-134 (e.g., 118, 119, 120, 121,122, 123, 124, 125, 126, 127, 128, 129, 130, 131, 132, 133, or 134) ofSEQ ID NO: 1 or 4. In some embodiments, the portion derived from ActRIIBcorresponds to a sequence beginning at any one of amino acids 20-29(e.g., 20, 21, 22, 23, 24, 25, 26, 27, 28, or 29) of SEQ ID NO: 1 or 4and ending at any one of amino acids 118-133 (e.g., 118, 119, 120, 121,122, 123, 124, 125, 126, 127, 128, 129, 130, 131, 132, or 133) of SEQ IDNO: 1 or 4. In some embodiments, the portion derived from ActRIIBcorresponds to a sequence beginning at one any of amino acids 21-29(e.g., 21, 22, 23, 24, 25, 26, 27, 28, or 29) of SEQ ID NO: 1 or 4 andending at any one of amino acids 128-134 (e.g., 128, 129, 130, 131, 132,133, or 134) of SEQ ID NO: 1 or 4. In some embodiments, the portionderived from ActRIIB corresponds to a sequence beginning at any one ofamino acids 20-29 (e.g., 20, 21, 22, 23, 24, 25, 26, 27, 28, or 29) ofSEQ ID NO: 1 or 4 and ending at any one of amino acids 128-133 (e.g.,128, 129, 130, 131, 132, or 133) of SEQ ID NO: 1 or 4. Surprisingly,ActRIIB and ActRIIB-based GDF Trap constructs beginning at 22-25 (e.g.,22, 23, 24, or 25) of SEQ ID NO: 1 or 4 have activity levels greaterthan proteins having the full extracellular domain of human ActRIIB. Insome embodiments, the ActRIIB polypeptides and ActRIIB-based GDF Trappolypeptides comprises, consists essentially of, or consists of, anamino acid sequence beginning at amino acid position 25 of SEQ ID NO: 1or 4 and ending at amino acid position 131 of SEQ ID NO: 1 or 4. Any ofthe foregoing ActRIIB polypeptide or ActRIIB-based GDF Trap polypeptidesmay be produced as a homodimer. Any of the foregoing ActRIIB polypeptideor ActRIIB-based GDF Trap polypeptides may further comprise aheterologous portion that comprises a constant region from an IgG heavychain, such as an Fc domain. Any of the above ActRIIB-based GDF Trappolypeptides may comprise an acidic amino acid at the positioncorresponding to position 79 of SEQ ID NO: 1, optionally in combinationwith one or more additional amino acid substitutions, deletions, orinsertions relative to SEQ ID NO: 1. Any of the above ActRIIBpolypeptides ActRIIB-based GDF Trap polypeptides, including homodimerand/or fusion proteins thereof, may bind to and/or inhibit signaling byactivin (e.g., activin A, activin B, activin C, or activin AB) in acell-based assay. Any of the above ActRIIB polypeptides ActRIIB-basedGDF Trap polypeptides, including homodimer and/or fusion proteinsthereof, may bind to and/or inhibit signaling by GDF11 and/or GDF8 in acell based assay. Optionally, any of the above ActRIIB polypeptidesActRIIB-based GDF Trap polypeptides, including homodimer and/or fusionproteins thereof, may bind to and/or inhibit signaling of one or more ofactivin B, activin C, activin E, BMP6, BMP7, and Nodal in a cell-basedassay.

Other ActRIIB polypeptides and ActRIIB-based GDF Trap polypeptides arecontemplated, such as the following. An ActRIIB polypeptide or GDF Trappolypeptide comprising an amino acid sequence that is at least 80%(e.g., 85%, 90%, 95%, 96%, 97%, 98%, 99%, or 100%) identical to thesequence of amino acids 29-109 of SEQ ID NO: 1 or 4, wherein theposition corresponding to 64 of SEQ ID NO: 1 is an R or K, and whereinthe ActRIIB polypeptide or ActRIIB-based GDF Trap polypeptide inhibitssignaling by activin, GDF8, and/or GDF11 in a cell-based assay. TheActRIIB polypeptide or ActRIIB-based GDF Trap polypeptide as above,wherein at least one alteration with respect to the sequence of SEQ IDNO: 1 or 4 is positioned outside of the ligand-binding pocket. TheActRIIB polypeptide or ActRIIB-based GDF Trap polypeptide as above,wherein at least one alteration with respect to the sequence of SEQ IDNO: 1 or 4 is a conservative alteration positioned within theligand-binding pocket. The ActRIIB polypeptide or ActRIIB-based GDF Trappolypeptide as above, wherein at least one alteration with respect tothe sequence of SEQ ID NO: 1 or 4 is an alteration at one or morepositions selected from the group consisting of K74, R40, Q53, K55, F82,and L79.

Other ActRIIB polypeptides and ActRIIB-based GDF Trap polypeptides arecontemplated, such as the following. An ActRIIB polypeptide orActRIIB-based GDF Trap polypeptide comprising an amino acid sequencethat is at least 80% (e.g., 85%, 90%, 95%, 96%, 97%, 98%, 99%, or 100%)identical to the sequence of amino acids 29-109 of SEQ ID NO: 1 or 4,and wherein the protein comprises at least one N-X-S/T sequence at aposition other than an endogenous N-X-S/T sequence of ActRIIB, and at aposition outside of the ligand binding pocket. The ActRIIB polypeptideor ActRIIB-based GDF Trap polypeptide as above, wherein the ActRIIBpolypeptide or ActRIIB-based GDF Trap polypeptide comprises an N at theposition corresponding to position 24 of SEQ ID NO: 1 or 4 and an S or Tat the position corresponding to position 26 of SEQ ID NO: 1 or 4, andwherein the ActRIIB polypeptide or ActRIIB-based GDF Trap polypeptideinhibits signaling by activin, GDF8, and/or GDF11 in a cell-based assay.The ActRIIB polypeptide or ActRIIB-based GDF Trap polypeptide as above,wherein the ActRIIB polypeptide or ActRIIB-based GDF Trap polypeptidecomprises an R or K at the position corresponding to position 64 of SEQID NO: 1 or 4. The ActRIIB polypeptide or ActRIIB-based GDF Trappolypeptide as above, wherein ActRIIB polypeptide or ActRIIB-based GDFTrap polypeptide comprises a D or E at the position corresponding toposition 79 of SEQ ID NO: 1 or 4, and wherein the ActRIIB polypeptide orActRIIB-based GDF Trap polypeptide inhibits signaling by activin, GDF8,and/or GDF11 in a cell-based assay. The ActRIIB polypeptide orActRIIB-based GDF Trap polypeptide as above, wherein at least onealteration with respect to the sequence of SEQ ID NO: 1 or 4 is aconservative alteration positioned within the ligand-binding pocket. TheActRIIB polypeptide or ActRIIB-based GDF Trap polypeptide as above,wherein at least one alteration with respect to the sequence of SEQ IDNO: 1 or 4 is an alteration at one or more positions selected from thegroup consisting of K74, R40, Q53, K55, F82, and L79. The ActRIIBpolypeptide or ActRIIB-based GDF Trap polypeptide above, wherein theActRIIB polypeptide or ActRIIB-based GDF Trap polypeptide is a fusionprotein further comprising one or more heterologous portion. Any of theabove ActRIIB polypeptides or ActRIIB-based GDF Trap polypeptides, orfusion proteins thereof, may be produced as a homodimer. Any of theabove ActRIIB fusion proteins or ActRIIB-based GDF Trap fusion proteinsmay have a heterologous portion that comprises a constant region from anIgG heavy chain, such as an Fc domain.

In certain embodiments, an ActRIIB polypeptide, for use in accordancewith the methods disclosed herein, comprises an amino acid sequence thatcomprises, consists of, or consists essentially of, the amino acidsequence of SEQ ID NOs: 2, 3, 5, 6, 29, 31, or 49, and polypeptides thatare at least 80%, 85%, 90%, 95%, 96%, 97%, 98%, or 99% identical to anyof the foregoing. An ActRIIB polypeptide may include a functionalfragment of a natural ActRIIB polypeptide, such as one comprising atleast 10, 20 or 30 amino acids of a sequence selected from SEQ ID NOs:2, 3, 5, 6, 29, 31, or 49 or a sequence of SEQ ID NO: 2 or 5, lackingthe C-terminal 1, 2, 3, 4, 5 or 10 to 15 amino acids and lacking 1, 2,3, 4 or 5 amino acids at the N-terminus. In some embodiments, apolypeptide will comprise a truncation relative to SEQ ID NO: 2 or 5 ofbetween 2 and 5 amino acids at the N-terminus and no more than 3 aminoacids at the C-terminus. In some embodiments, a GDF Trap for use inaccordance with the methods described herein consists of, or consistsessentially of, the amino acid sequence of SEQ ID NO:29.

A general formula for an active (e.g., ligand binding) ActRIIApolypeptide is one that comprises a polypeptide that starts at aminoacid 30 and ends at amino acid 110 of SEQ ID NO:9. Accordingly, ActRIIApolypeptides and ActRIIA-based GDF Traps of the present disclosure maycomprise, consist, or consist essentially of a polypeptide that is atleast 80%, 85%, 90%, 95%, 96%, 97%, 98%, 99%, or 100% identical to aminoacids 30-110 of SEQ ID NO:9. Optionally, ActRIIA polypeptides andActRIIA-based GDF Trap polypeptides of the present disclosure comprise,consists, or consist essentially of a polypeptide that is at least 80%,85%, 90%, 95%, 96%, 97%, 98%, 99%, or 100% identical to amino acidsamino acids 12-82 of SEQ ID NO:9 optionally beginning at a positionranging from 1-5 (e.g., 1, 2, 3, 4, or 5) or 3-5 (e.g., 3, 4, or 5) andending at a position ranging from 110-116 (e.g., 110, 111, 112, 113,114, 115, or 116) or 110-115 (e.g., 110, 111, 112, 113, 114. or 115) orSEQ ID NO:9, respectively, and comprising no more than 1, 2, 5, 10 or 15conservative amino acid changes in the ligand binding pocket, and zero,one or more non-conservative alterations at positions 40, 53, 55, 74, 79and/or 82 in the ligand-binding pocket with respect to SEQ ID NO:9. Anyof the foregoing ActRIIA polypeptide or ActRIIA-based GDF Trappolypeptides may be produced as a homodimer. Any of the foregoingActRIIA polypeptide or ActRIIA-based GDF Trap polypeptides may furthercomprise a heterologous portion that comprises a constant region from anIgG heavy chain, such as an Fc domain. Any of the above ActRIIApolypeptides ActRIIA-based GDF Trap polypeptides, including homodimerand/or fusion proteins thereof, may bind to and/or inhibit signaling byactivin (e.g., activin A, activin B, activin C, or activin AB) in acell-based assay. Any of the above ActRIIA polypeptides ActRIIA-basedGDF Trap polypeptides, including homodimer and/or fusion proteinsthereof, may bind to and/or inhibit signaling by GDF11 and/or GDF8 in acell based assay. Optionally, any of the above ActRIIA polypeptidesActRIIB-based GDF Trap polypeptides, including homodimer and/or fusionproteins thereof, may bind to and/or inhibit signaling of one or more ofactivin B, activin C, activin E, GDF7, and Nodal in a cell-based assay.

In certain embodiments, ActRIIA polypeptides and ActRIIA-based GDF-Trappolypeptides, for use in accordance with the methods disclosed herein,comprises an amino acid sequence that comprises, consists of, orconsists essentially of, the amino acid sequence of SEQ ID NOs: 9, 10,22, 26, or 28, and polypeptides that are at least 80%, 85%, 90%, 95%,96%, 97%, 98%, or 99% identical to any of the foregoing. An ActRIIApolypeptide or ActRIIA-based GDF-Trap polypeptide may include afunctional fragment of a natural ActRIIA polypeptide, such as onecomprising at least 10, 20 or 30 amino acids of a sequence selected fromSEQ ID NOs: 9, 10, 22, 26, or 28 or a sequence of SEQ ID NO:10, lackingthe C-terminal 1, 2, 3, 4, 5 or 10 to 15 amino acids and lacking 1, 2,3, 4 or 5 amino acids at the N-terminus. In some embodiments, apolypeptide will comprise a truncation relative to SEQ ID NO: 10 ofbetween 2 and 5 amino acids at the N-terminus and no more than 3 aminoacids at the C-terminus. In some embodiments, an ActRIIA polypeptide foruse in the methods described herein consists of, or consists essentiallyof, the amino acid sequence of SEQ ID NO: 26 or 28.

An ActRII polypeptide (e.g. an ActRIIA or ActRIIB polypeptide) or GDFTrap polypeptide of the disclosure may include one or more alterations(e.g., amino acid additions, deletions, substitutions, or combinationsthereof) in the amino acid sequence of an ActRII polypeptide (e.g., inthe ligand-binding domain) relative to a naturally occurring ActRIIpolypeptide. The alteration in the amino acid sequence may, for example,alter glycosylation of the polypeptide when produced in a mammalian,insect, or other eukaryotic cell or alter proteolytic cleavage of thepolypeptide relative to the naturally occurring ActRII polypeptide.

Optionally, ActRII polypeptides (e.g. an ActRIIA or ActRIIBpolypeptides) and GDF Trap polypeptides of the disclosure comprise oneor more modified amino acid residues selected from: a glycosylated aminoacid, a PEGylated amino acid, a farnesylated amino acid, an acetylatedamino acid, a biotinylated amino acid, an amino acid conjugated to alipid moiety, and an amino acid conjugated to an organic derivatizingagent.

In some embodiments, an ActRII polypeptide (e.g. an ActRIIA or ActRIIBpolypeptide) or GDF Trap polypeptide of the disclosure may be a fusionprotein that has, as one domain, an ActRII polypeptide or GDF Trappolypeptide (e.g., a ligand-binding domain of an ActRII receptor,optionally with one or more sequence variations) and one or moreadditional heterologous domains that provide a desirable property, suchas improved pharmacokinetics, easier purification, targeting toparticular tissues, etc. For example, a domain of a fusion protein mayenhance one or more of in vivo stability, in vivo half-life,uptake/administration, tissue localization or distribution, formation ofprotein complexes, multimerization of the fusion protein, and/orpurification. ActRII polypeptide and GDF Trap fusion proteins mayinclude a heterologous polypeptide domain such as but not limited to, animmunoglobulin Fc domain (wild-type or mutant) or a serum albumin. Insome embodiments, the immunoglobulin Fc domain is an IgG1 Fc domain. Insome embodiments, the IgG1 Fc domain is a human IgG1 Fc domain. In someembodiments, the IgG1 Fc domain is a mouse IgG1 Fc domain. In certainembodiments, an ActRII polypeptide and GDF Trap polypeptide fusionprotein comprises a relatively unstructured linker positioned betweenthe ActRII or GDF Trap polypeptide domain and the heterologous domain.In certain embodiments, an ActRII polypeptide and GDF Trap fusionprotein comprises a relatively unstructured linker positioned betweenthe Fc domain and the ActRII or GDF Trap domain. This unstructuredlinker may correspond to the roughly 15 amino acid unstructured regionat the C-terminal end of the extracellular domain of ActRII or GDF Trap(the “tail”), or it may be an artificial sequence of between 3 and 5,15, 20, 30, 50 or more amino acids that are relatively free of secondarystructure. A linker may be rich in glycine and proline residues and may,for example, contain repeating sequences of threonine/serine andglycines [e.g., TG₄ (SEQ ID NO:52), SG₄ (SEQ ID NO:54), or TG₃ (SEQ IDNO:53) singlets or repeats] or a series of three glycines. A fusionprotein may include a purification subsequence, such as an epitope tag,a FLAG tag, a polyhistidine sequence, and a GST fusion. In certainembodiments, an ActRII fusion protein or GDF Trap fusion comprises aleader sequence. The leader sequence may be a native ActRII leadersequence (e.g., a native ActRIIA or ActRIIB leader sequence) or aheterologous leader sequence. In certain embodiments, the leadersequence is a Tissue Plasminogen Activator (TPA) leader sequence. Insome embodiments, an ActRII fusion protein or GDF Trap fusion proteincomprises an amino acid sequence as set forth in the formula A-B-C. TheB portion is an N- and C-terminally truncated ActRII or GDF Trappolypeptide as described herein. The A and C portions may beindependently zero, one or more than one amino acids, and both A and Cportions are heterologous to B. The A and/or C portions may be attachedto the B portion via a linker sequence.

Optionally, ActRII polypeptides (e.g., ActRIIA and ActRIIB polypeptides)GDF Trap polypeptides, including variants and fusion proteins thereof,to be used in accordance with the methods disclosed herein bind to oneor more ActRIIB ligand (e.g., activin A, activin B, activin AB, activinC, activin E, GDF11, GDF8, BMP6, BMP7, and/or Nodal) with a Kd less than10 micromolar, less than 1 micromolar, less than 100 nanomolar, lessthan 10 nanomolar, or less than 1 nanomolar. Optionally, such ActRIIpolypeptides GDF Trap polypeptides inhibit ActRII signaling, such asActRIIA and/or ActRIIB intracellular signal transduction eventstriggered by an ActRII ligand (e.g., SMAD 2/3 and/or SMAD 1/5/8signaling).

In certain aspects, the disclosure provides pharmaceutical preparationsor compositions comprising an ActRII antagonist of the presentdisclosure (e.g., an ActRIIA polypeptide, and ActRIIB polypeptide, a GDFTrap polypeptide) and a pharmaceutically acceptable carrier. Apharmaceutical preparation or composition may also include one or moreadditional compounds such as a compound that is used to treat a disorderor condition described herein (e.g., an addition compound that increasesred blood cell levels and/or hemoglobin levels in a subject in needthereof, treats or prevents anemia in a subject in need thereof, treator prevents an ulcer, particularly a cutaneous ulcer, a subject in needthereof). Preferably, a pharmaceutical preparation or composition of thedisclosure is substantially pyrogen-free.

In general, it is preferable that an ActRIIA polypeptide, and ActRIIBpolypeptide, or a GDF Trap polypeptide be expressed in a mammalian cellline that mediates suitably natural glycosylation of the polypeptide soas to diminish the likelihood of an unfavorable immune response in apatient. Human and CHO cell lines have been used successfully, and it isexpected that other common mammalian expression vectors will be useful.In some embodiments, preferable ActRIIA polypeptides, ActRIIBpolypeptides, and GDF Trap polypeptides are glycosylated and have aglycosylation pattern that is obtainable from a mammalian cell,preferably a CHO cell.

In certain embodiments, the disclosure provides packaged pharmaceuticalscomprising a pharmaceutical preparation or composition described hereinand labeled for use in one or more of increasing red blood cell levelsand/or hemoglobin in a mammal (preferably a human), treating orpreventing anemia in a mammal (preferably a human), treating orpreventing sickle cell disease in a mammal (preferably a human), and/ortreating or preventing one or more complications of sickle-cell disease(e.g., anemia, vaso-occlusive crisis, ulcers (such as cutaneous ulcers),etc.) in a mammal (preferably a human). In certain embodiments, thedisclosure provides packaged pharmaceuticals comprising a pharmaceuticalpreparation or composition described herein and labeled for use intreating anemia in a mammal (preferably a human), treating sickle celldisease in a mammal (preferably a human), and/or treating one or morecomplications of sickle-cell disease (e.g., anemia, vaso-occlusivecrisis, ulcers (such as cutaneous ulcers), etc.) in a mammal (preferablya human). In certain embodiments, the disclosure provides packagedpharmaceuticals comprising a pharmaceutical preparation or compositiondescribed herein and labeled for use in preventing anemia in a mammal(preferably a human), preventing sickle cell disease in a mammal(preferably a human), and/or treating or preventing one or morecomplications of sickle-cell disease (e.g., anemia, vaso-occlusivecrisis, ulcers (such as cutaneous ulcers), etc.) in a mammal (preferablya human).

In certain aspects, the disclosure provides nucleic acids encoding anActRII polypeptide (e.g., an ActRIIA or ActRIIB polypeptide) or GDF Trappolypeptide. An isolated polynucleotide may comprise a coding sequencefor a soluble ActRII polypeptide or GDF Trap polypeptide, such asdescribed herein. For example, an isolated nucleic acid may include asequence coding for an ActRII polypeptide or GDF Trap comprising anextracellular domain (e.g., ligand-binding domain) of an ActRIIpolypeptide having one or more sequence variations and a sequence thatwould code for part or all of the transmembrane domain and/or thecytoplasmic domain of an ActRII polypeptide, but for a stop codonpositioned within the transmembrane domain or the cytoplasmic domain, orpositioned between the extracellular domain and the transmembrane domainor cytoplasmic domain. For example, an isolated polynucleotide codingfor a GDF Trap may comprise a full-length ActRII polynucleotide sequencesuch as SEQ ID NO: 1, 4, or 9 or having one or more variations, or apartially truncated version, said isolated polynucleotide furthercomprising a transcription termination codon at least six hundrednucleotides before the 3′-terminus or otherwise positioned such thattranslation of the polynucleotide gives rise to an extracellular domainoptionally fused to a truncated portion of a full-length ActRII. Nucleicacids disclosed herein may be operably linked to a promoter forexpression, and the disclosure provides cells transformed with suchrecombinant polynucleotides. Preferably the cell is a mammalian cell,such as a CHO cell.

In certain aspects, the disclosure provides methods for making an ActRIIpolypeptide or GDF Trap. Such a method may include expressing any of thenucleic acids disclosed herein (e.g., SEQ ID NO: 8, 13, 27, 32, 39, 42,46, or 48) in a suitable cell, such as a Chinese hamster ovary (CHO)cell. Such a method may comprise: a) culturing a cell under conditionssuitable for expression of the GDF Trap polypeptide, wherein said cellis transformed with a GDF Trap expression construct; and b) recoveringthe GDF Trap polypeptide so expressed. GDF Trap polypeptides may berecovered as crude, partially purified or highly purified fractionsusing any of the well-known techniques for obtaining protein from cellcultures.

In certain aspects, the present disclosure relates to an antibody, orcombination of antibodies, that antagonize ActRII activity (e.g.,inhibition of ActRIIA and/or ActRIIB signaling transduction, such asSMAD 2/3 and/or SMAD 1/5/8 signaling). In particular, the disclosureprovides methods of using an antibody ActRII antagonist, or combinationof antibody ActRII antagonists, to, e.g., increase red blood cell levelsin a subject in need thereof, treat or prevent an anemia in a subject inneed thereof, and/or treat or prevent an ulcer, particularly a cutaneousulcer, in a subject that has anemia. In some embodiments, the disclosureprovides methods of using an antibody ActRII antagonist, or combinationof antibody ActRII antagonists to treat an ulcer, particularly acutaneous ulcer, in a subject that has anemia. In some embodiments, thedisclosure provides methods of using an antibody ActRII antagonist, orcombination of antibody ActRII antagonists to prevent an ulcer,particularly a cutaneous ulcer, in a subject that has anemia.

In certain embodiments, an antibody ActRII antagonist of the disclosureis an antibody, or combination of antibodies, that binds to and/orinhibits activity of at least GDF11 (e.g., GDF11-mediated activation ofActRIIA and/or ActRIIB signaling transduction, such as SMAD 2/3signaling). Optionally, the antibody, or combination of antibodies,further binds to and/or inhibits activity of GDF8 (e.g., GDF8-mediatedactivation of ActRIIA and/or ActRIIB signaling transduction, such asSMAD 2/3 signaling), particularly in the case of a multi-specificantibody that has binding affinity for both GDF11 and GDF8 or in thecontext of a combination of one or more anti-GDF11 antibody and one ormore anti-GDF8 antibody. Optionally, an antibody, or combination ofantibodies, of the disclosure does not substantially bind to and/orinhibit activity of activin A (e.g., activin A-mediated activation ofActRIIA or ActRIIB signaling transduction, such as SMAD 2/3 signaling).In some embodiments, an antibody, or combination of antibodies, of thedisclosure that binds to and/or inhibits the activity of GDF11 and/orGDF8 further binds to and/or inhibits activity of one of more of activinA, activin B, activin AB, activin C, activin E, BMP6, BMP7, and Nodal(e.g., activation of ActRIIA or ActRIIB signaling transduction, such asSMAD 2/3 and/or SMAD 1/5/8 signaling), particularly in the case of amulti-specific antibody that has binding affinity for multiple ActRIIligands or in the context of a combination multiple antibodies—eachhaving binding affinity for a different ActRII ligand.

In part, the disclosure demonstrates that ActRII antagonists may be usedin combination (e.g., administered at the same time or different times,but generally in such a manner as to achieve overlapping pharmacologicaleffects) with EPO receptor activators to increase red blood cell levels(erythropoiesis) or treat anemia in patients in need thereof. In part,the disclosure demonstrates that a GDF Trap can be administered incombination with an EPO receptor activator to synergistically increaseformation of red blood cells in a patient, particularly in sickle-cellpatients. Thus, the effect of this combined treatment can besignificantly greater than the sum of the effects of the ActRIIantagonists and the EPO receptor activator when administered separatelyat their respective doses. In certain embodiments, this synergism may beadvantageous since it enables target levels of red blood cells to beattained with lower doses of an EPO receptor activator, thereby avoidingpotential adverse effects or other problems associated with higherlevels of EPO receptor activation. Accordingly, in certain embodiments,the methods of the present disclosure (e.g., methods of increasing redblood cell levels and/or hemoglobin in a subject in need thereof,treating or preventing anemia in a subject in need thereof, and/ortreating or preventing an ulcer in a subject that has anemia) compriseadministering a patient in need thereof one or more ActRII antagonists(e.g., ActRIIA polypeptides, ActRIIB polypeptides, and/or GDF Trappolypeptides) in combination with one or more EPO receptor activators.

An EPO receptor activator may stimulate erythropoiesis by directlycontacting and activating EPO receptor. In certain embodiments, the EPOreceptor activator is one of a class of compounds based on the 165amino-acid sequence of native EPO and generally known aserythropoiesis-stimulating agents (ESAs), examples of which are epoetinalfa, epoetin beta (NeoRecormon®), epoetin delta (Dynepo™), and epoetinomega. In other embodiments, ESAs include synthetic EPO proteins (SEPs)and EPO derivatives with nonpeptidic modifications conferring desirablepharmacokinetic properties (lengthened circulating half-life), examplesof which are darbepoetin alfa (Aranesp®) and methoxy-polyethylene-glycolepoetin beta (Mircera®). In certain embodiments, an EPO receptoractivator may be an EPO receptor agonist that does not incorporate theEPO polypeptide backbone or is not generally classified as an ESA. SuchEPO receptor agonists may include, but are not limited to, peptidic andnonpeptidic mimetics of EPO, agonistic antibodies targeting EPOreceptor, fusion proteins comprising an EPO mimetic domain, anderythropoietin receptor extended-duration limited agonists (EREDLA).

In certain embodiments, an EPO receptor activator may stimulateerythropoiesis indirectly, without contacting EPO receptor itself, byenhancing production of endogenous EPO. For example, hypoxia-inducibletranscription factors (HIFs) are endogenous stimulators of EPO geneexpression that are suppressed (destabilized) under normoxic conditionsby cellular regulatory mechanisms. In part, the disclosure providesincreased erythropoiesis in a patient by combined treatment with a GDFTrap and an indirect EPO receptor activator with HIF stabilizingproperties, such as a prolyl hydroxylase inhibitor.

ActRII antagonists, particularly ActRII polypeptides and GDF Trappolypeptides, may also be used for treating or preventing otherdisorders and conditions such as promoting muscle growth and/or treatingor preventing a muscle-related disorder, promoting bone growth and/ortreating or preventing a bone-related disorder, treating or preventingcancer (particularly multiple myeloma and/or breast cancer). See, e.g.,U.S. Pat. Nos. 7,612,041; 8,173,601; 7,842,663 as well as U.S. PatentApplication Publication No. U.S. 2009/0074768. In certain instances,when administering a GDF Trap polypeptide for these other therapeuticindications, it may be desirable to monitor the effects on red bloodcells during administration of the ActRII antagonist, or to determine oradjust the dosing of the ActRII antagonist, in order to reduce undesiredeffects on red blood cells. For example, increases in red blood celllevels, hemoglobin levels, or hematocrit levels may cause increases inblood pressure.

BRIEF DESCRIPTION OF THE DRAWINGS

The patent or patent application file contains at least one drawingexecuted in color. Copies of this patent or patent applicationpublication with color drawing(s) will be provided by the Office uponrequest and payment of the necessary fee.

FIG. 1 shows an alignment of extracellular domains of human ActRIIA (SEQID NO:56) and human ActRIIB (SEQ ID NO:2)with the residues that arededuced herein, based on composite analysis of multiple ActRIIB andActRIIA crystal structures, to directly contact ligand indicated withboxes.

FIG. 2 shows a multiple sequence alignment of various vertebrate ActRIIBproteins and human ActRIIA (SEQ ID Nos: 57-63 and 69.

FIGS. 3A and 3B shows the purification of ActRIIA-hFc expressed in CHOcells. The protein purifies as a single, well-defined peak as visualizedby sizing column (top panel) and Coomassie stained SDS-PAGE (bottompanel) (left lane: molecular weight standards; right lane: ActRIIA-hFc).

FIGS. 4A and 4B shows the binding of ActRIIA-hFc to activin and GDF-11,as measured by Biacore™ assay.

FIGS. 5A and 5B show the effects of ActRIIA-hFc on red blood cell countsin female non-human primates (NHPs). Female cynomolgus monkeys (fourgroups of five monkeys each) were treated with placebo or 1 mg/kg, 10mg/kg or 30 mg/kg of ActRIIA-hFc on day 0, day 7, day 14 and day 21.FIG. 5A shows red blood cell (RBC) counts. FIG. 5B shows hemoglobinlevels. Statistical significance is relative to baseline for eachtreatment group. At day 57, two monkeys remained in each group.

FIGS. 6A and 6B shows the effects of ActRIIA-hFc on red blood cellcounts in male non-human primates. Male cynomolgus monkeys (four groupsof five monkeys each) were treated with placebo or 1 mg/kg, 10 mg/kg, or30 mg/kg of ActRIIA-hFc on day 0, day 7, day 14, and day 21. FIG. 6Ashows red blood cell (RBC) counts. FIG. 6B shows hemoglobin levels.Statistical significance is relative to baseline for each treatmentgroup. At day 57, two monkeys remained in each group.

FIGS. 7A and 7B shows the effects of ActRIIA-hFc on reticulocyte countsin female non-human primates. Cynomolgus monkeys (four groups of fivemonkeys each) were treated with placebo or 1 mg/kg, 10 mg/kg, or 30mg/kg of ActRIIA-hFc on day 0, day 7, day 14, and day 21. FIG. 7A showsabsolute reticulocyte counts. FIG. 7B shows the percentage ofreticulocytes relative to RBCs. Statistical significance is relative tobaseline for each group. At day 57, two monkeys remained in each group.

FIGS. 8A and 8B shows the effects of ActRIIA-hFc on reticulocyte countsin male non-human primates. Cynomolgus monkeys (four groups of fivemonkeys each) were treated with placebo or 1 mg/kg, 10 mg/kg or 30 mg/kgof ActRIIA-hFc on day 0, day 7, day 14 and day 21. FIG. 8A showsabsolute reticulocyte counts. FIG. 8B shows the percentage ofreticulocytes relative to RBCs. Statistical significance is relative tobaseline for each group. At day 57, two monkeys remained in each group.

FIG. 9 shows results from the human clinical trial described in Example5, where the area-under-curve (AUC) and administered dose of ActRIIA-hFchave a linear correlation, regardless of whether ActRIIA-hFc wasadministered intravenously (IV) or subcutaneously (SC).

FIG. 10 shows a comparison of serum levels of ActRIIA-hFc in patientsadministered IV or SC.

FIG. 11 shows bone alkaline phosphatase (BAP) levels in response todifferent dose levels of ActRIIA-hFc. BAP is a marker for anabolic bonegrowth.

FIG. 12 depicts the median change from baseline of hematocrit levelsfrom the human clinical trial described in Example 5. ActRIIA-hFc wasadministered intravenously (IV) at the indicated dosage.

FIG. 13 depicts the median change from baseline of hemoglobin levelsfrom the human clinical trial described in Example 5. ActRIIA-hFc wasadministered intravenously (IV) at the indicated dosage.

FIG. 14 depicts the median change from baseline of RBC (red blood cell)count from the human clinical trial described in Example 5. ActRIIA-hFcwas administered intravenously (IV) at the indicated dosage.

FIG. 15 depicts the median change from baseline of reticulocyte countfrom the human clinical trial described in Example 5. ActRIIA-hFc wasadministered intravenously (IV) at the indicated dosage.

FIG. 16 shows the full amino acid sequence for the GDF Trap ActRIIB(L79D20-134)-hFc (SEQ ID NO:38), including the TPA leader sequence (doubleunderlined), ActRIIB extracellular domain (residues 20-134 in SEQ ID NO:1; underlined), and hFc domain. The aspartate substituted at position 79in the native sequence is double underlined and highlighted, as is theglycine revealed by sequencing to be the N-terminal residue in themature fusion protein.

FIGS. 17A and 17B show a nucleotide sequence encoding ActRIIB(L79D20-134)-hFc. SEQ ID NO:39 corresponds to the sense strand, and SEQ IDNO:40 corresponds to the antisense strand. The TPA leader (nucleotides1-66) is double underlined, and the ActRIIB extracellular domain(nucleotides 76-420) is underlined.

FIG. 18 shows the full amino acid sequence for the truncated GDF TrapActRIIB(L79D 25-131)-hFc (SEQ ID NO:41), including the TPA leader(double underlined), truncated ActRIIB extracellular domain (residues25-131 in SEQ ID NO: 1; underlined), and hFc domain. The aspartatesubstituted at position 79 in the native sequence is double underlinedand highlighted, as is the glutamate revealed by sequencing to be theN-terminal residue in the mature fusion protein.

FIGS. 19A and 19B show a nucleotide sequence encoding ActRIIB(L79D25-131)-hFc. SEQ ID NO:42 corresponds to the sense strand, and SEQ IDNO:43 corresponds to the antisense strand. The TPA leader (nucleotides1-66) is double underlined, and the truncated ActRIIB extracellulardomain (nucleotides 76-396) is underlined. The amino acid sequence forthe ActRIIB extracellular domain (residues 25-131 in SEQ ID NO: 1) isalso shown (SEQ ID NO:45).

FIG. 20 shows the amino acid sequence for the truncated GDF TrapActRIIB(L79D 25-131)-hFc without a leader (SEQ ID NO:44). The truncatedActRIIB extracellular domain (residues 25-131 in SEQ ID NO:1) isunderlined. The aspartate substituted at position 79 in the nativesequence is double underlined and highlighted, as is the glutamaterevealed by sequencing to be the N-terminal residue in the mature fusionprotein.

FIG. 21 shows the amino acid sequence for the truncated GDF TrapActRIIB(L79D 25-131) without the leader, hFc domain, and linker (SEQ IDNO:45). The aspartate substituted at position 79 in the native sequenceis underlined and highlighted, as is the glutamate revealed bysequencing to be the N-terminal residue in the mature fusion protein.

FIGS. 22A and 22B show an alternative nucleotide sequence encodingActRIIB(L79D 25-131)-hFc. SEQ ID NO:46 corresponds to the sense strand,and SEQ ID NO:47 corresponds to the antisense strand. The TPA leader(nucleotides 1-66) is double underlined, the truncated ActRIIBextracellular domain (nucleotides 76-396) is underlined, andsubstitutions in the wild-type nucleotide sequence of the extracellulardomain are double underlined and highlighted (compare with SEQ ID NO:42,FIG. 19). The amino acid sequence for the ActRIIB extracellular domain(residues 25-131 in SEQ ID NO:1) is also shown (SEQ ID NO:45).

FIG. 23 shows nucleotides 76-396 (SEQ ID NO:48) of the alternativenucleotide sequence shown in FIG. 22 (SEQ ID NO:46). The same nucleotidesubstitutions indicated in FIG. 22 are also underlined and highlightedhere. SEQ ID NO:48 encodes only the truncated ActRIIB extracellulardomain (corresponding to residues 25-131 in SEQ ID NO:1) with a L79Dsubstitution, e.g., ActRIIB(L79D 25-131).

FIG. 24 shows the effect of treatment with ActRIIB(L79D 20-134)-hFc(gray) or ActRIIB(L79D 25-131)-hFc (black) on the absolute change in redblood cell concentration from baseline in cynomolgus monkey.VEH=vehicle. Data are means±SEM. n=4-8 per group.

FIG. 25 shows the effect of treatment with ActRIIB(L79D 20-134)-hFc(gray) or ActRIIB(L79D 25-131)-hFc (black) on the absolute change inhematocrit from baseline in cynomolgus monkey. VEH=vehicle. Data aremeans±SEM. n=4-8 per group.

FIG. 26 shows the effect of treatment with ActRIIB(L79D 20-134)-hFc(gray) or ActRIIB(L79D 25-131)-hFc (black) on the absolute change inhemoglobin concentration from baseline in cynomolgus monkey.VEH=vehicle. Data are means±SEM. n=4-8 per group.

FIG. 27 shows the effect of treatment with ActRIIB(L79D 20-134)-hFc(gray) or ActRIIB(L79D 25-131)-hFc (black) on the absolute change incirculating reticulocyte concentration from baseline in cynomolgusmonkey. VEH=vehicle. Data are means±SEM. n=4-8 per group.

FIG. 28 shows the effect of combined treatment with erythropoietin (EPO)and ActRIIB(L79D 25-131)-hFc for 72 hours on hematocrit in mice. Dataare means±SEM (n=4 per group), and means that are significantlydifferent from each other (p<0.05, unpaired t-test) are designated bydifferent letters. Combined treatment increased hematocrit by 23%compared to vehicle, a synergistic increase greater than the sum of theseparate effects of EPO and ActRIIB(L79D 25-131)-hFc.

FIG. 29 shows the effect of combined treatment with EPO and ActRIIB(L79D25-131)-hFc for 72 hours on hemoglobin concentrations in mice. Data aremeans±SEM (n=4 per group), and means that are significantly differentfrom each other (p<0.05) are designated by different letters. Combinedtreatment increased hemoglobin concentrations by 23% compared tovehicle, which was also a synergistic effect.

FIG. 30 shows the effect of combined treatment with EPO and ActRIIB(L79D25-131)-hFc for 72 hours on red blood cell concentrations in mice. Dataare means±SEM (n=4 per group), and means that are significantlydifferent from each other (p<0.05) are designated by different letters.Combined treatment increased red blood cell concentrations by 20%compared to vehicle, which was also a synergistic effect.

FIG. 31 shows the effect of combined treatment with EPO and ActRIIB(L79D25-131)-hFc for 72 hours on numbers of erythropoietic precursor cells inmouse spleen. Data are means±SEM (n=4 per group), and means that aresignificantly different from each other (p<0.01) are designated bydifferent letters. Whereas EPO alone increased the number of basophilicerythroblasts (BasoE) dramatically at the expense of late-stageprecursor maturation, combined treatment increased BasoE numbers to alesser but still significant extent while supporting undiminishedmaturation of late-stage precursors.

FIGS. 32A-C compares RBC parameters in an Hbb^(−/−) mouse model ofβ-thalassemia with those in wildtype (WT) mice. Blood samples fromuntreated mice at 2-6 months of age were analyzed to determine red bloodcell number (RBC; A), hematocrit (HCT; B), and hemoglobin concentration(Hgb; C). Data are means±SEM (n=4 per group), ***, p<0.001. Hbb^(−/−)mice were confirmed to be severely anemic.

FIG. 33 shows the effect of ActRIIB(L79D 25-131)-mFc on RBC number in anHbb^(−/−) mouse model of β-thalassemia. Blood samples were collectedafter 4 weeks of treatment. Data are means of 2 per group, with barsindicating the range. Treatment with ActRIIB(L79D 25-131)-mFc reduced byhalf the RBC deficit present in Hbb^(−/−) mice.

FIG. 34 shows the effect of ActRIIB(L79D 25-131)-mFc on RBC morphologyin an Hbb^(−/−) mouse model of β-thalassemia. Images of Giemsa-stainedblood smears from mice treated for 4 weeks were obtained at 100×magnification. Note hemolysis, cellular debris, and many small orirregularly shaped RBCs in blood from the vehicle-treated Hbb^(−/−)mouse. By comparison, ActRIIB(L79D 25-131)-mFc treatment greatly reducedhemolysis, debris, and the occurrence of irregularly shaped RBCs whileincreasing the number of normally shaped RBCs.

FIG. 35 shows the effect of ActRIIB(L79D 25-131)-mFc treatment for 2months on RBC number in an Hbb^(−/−) mouse model of β-thalassemia, withdata from vehicle-dosed wildtype mice included for comparison. Data aremeans±SEM; n=7 per group. **, P<0.01 vs. vehicle-treated Hbb^(−/−) mice.Treatment with ActRIIB (L79D 25-131)-mFc reduced the mean RBC deficit inHbb^(−/−) mice by more than 50%.

FIG. 36 shows the effect of ActRIIB(L79D 25-131)-mFc treatment for 2months on serum bilirubin levels in an Hbb^(−/−) mouse model ofβ-thalassemia, with data from vehicle-dosed wildtype mice included forcomparison. Data are means±SEM. ###, P<0.001 vs. vehicle-treatedwildtype mice; *, P<0.05 vs. vehicle-treated Hbb^(−/−) mice. Treatmentwith ActRIIB(L79D 25-131)-mFc reduced total bilirubin levelssignificantly in Hbb^(−/−) mice.

FIG. 37 shows the effect of ActRIIB(L79D 25-131)-mFc treatment for 2months on serum EPO level in an Hbb^(−/−) mouse model of β-thalassemia,with data from vehicle-dosed wildtype mice included for comparison. Dataare means±SEM. ###, P<0.001 vs. vehicle-treated wildtype mice; *, P<0.05vs. vehicle-treated Hbb^(−/−) mice. Treatment with ActRIIB(L79D25-131)-mFc reduced mean circulating EPO levels by more than 60% inHbb^(−/−) mice.

FIGS. 38A and 38B show the effect of ActRIIB(L79D 25-131)-mFc onsplenomegaly in an Hbb^(−/−) mouse model of β-thalassemia, with datafrom vehicle-dosed wildtype mice included for comparison. A. Means±SEMfrom mice starting at 3 months of age after treatment with 1 mg/kg twiceweekly for 2 months. ###. P<0.001 vs. vehicle-treated wildtype mice; *,P<0.05 vs. vehicle-treated Hbb^(−/−) mice. B. Representative spleensizes, as observed in a separate study in mice starting at 6-8 months ofage after treatment with 1 mg/kg twice weekly for 3 months. Treatmentwith ActRIIB(L79D 25-131)-mFc reduced spleen weight significantly inHbb^(−/−) mice.

FIG. 39 shows the effect of ActRIIB(L79D 25-131)-mFc treatment for 2months on bone mineral density in an Hbb^(−/−) mouse model ofβ-thalassemia, with data from vehicle-dosed wildtype mice included forcomparison. Means±SEM based on femur analysis. #, P<0.05 vs.vehicle-treated wildtype mice; *, P<0.05 vs. vehicle-treated Hbb^(−/−)mice. Treatment with ActRIIB(L79D 25-131)-mFc normalized bone mineraldensity in Hbb^(−/−) mice.

FIGS. 40A-C show the effect of ActRIIB(L79D 25-131)-mFc treatment for 2months on parameters of iron homeostasis in an Hbb^(−/−) mouse model ofβ-thalassemia. Means±SEM for serum iron (A), serum ferritin (B), andtransferin saturation (C). *, P<0.05; **, P<0.01 vs. vehicle-treatedHbb^(−/−) mice. Treatment with ActRIIB(L79D 25-131)-mFc reduced eachmeasure of iron overload significantly in Hbb^(−/−) mice.

FIG. 41 shows the effect of ActRIIB(L79D 25-131)-mFc treatment for 2months on tissue iron overload in an Hbb^(−/−) mouse model ofβ-thalassemia. Iron levels in tissue sections (200 μm) from spleen(A-C), liver (D-F), and kidney (G-I) were determined by staining withPerl's Prussian blue. Iron staining in wildtype spleen (A) was abundantin red pulp (arrows) but absent in white pulp (*). Increased ironstaining in spleen of Hbb^(−/−) mice (B) reflects expansion of red pulpregions due to extramedullary erythropoiesis. ActRIIB(L79D 25-131)-mFcin Hbb^(−/−) mice decreased splenic erythropoiesis and restored thewildtype pattern of splenic iron staining (C) In addition, abnormal ironstaining in hepatic Kupffer cells (H, arrows) and renal cortex (E,arrows) of Hbb^(−/−) mice was normalized by ActRIIB(L79D 25-131)-mFc (Fand I). Magnification, 200×.

FIG. 42 shows the effect of ActRIIB(L79D 25-131)-mFc treatment for 2months on hepatic levels of hepcidin mRNA in a Hbb^(−/−) mouse model ofβ-thalassemia. Means±SEM; *, P<0.05 vs. vehicle-treated Hbb^(−/−) mice.Treatment with ActRIIB(L79D 25-131)-mFc increased expression of hepcidinmRNA significantly in Hbb^(−/−) mice.

FIG. 43 shows the effect of ActRIIB(L79D 25-131)-mFc on circulatinglevels of reactive oxygen species (ROS) in an Hbb^(−/−) mouse model ofβ-thalassemia, with data from vehicle-dosed wildtype mice included forcomparison. Data are geometric means±SEM. ###, P<0.001 vs.vehicle-treated wildtype mice; ***, P<0.001 vs. vehicle-treatedHbb^(−/−) mice. Treatment with ActRIIB(L79D 25-131)-mFc reduced ROSsignificantly in Hbb^(−/−) mice.

FIG. 44 shows the effect of ActRIIB(L79D 25-131)-mFc on the absolutechange in red blood cell concentration in sickle-cell disease (SCD)mice. Data are means±SEM (n=5 per group). Wt=wild-type mice, which werenon-symptomatic compound heterozygote (β/β^(S)) mice. ActRIIB(L79D25-131)-mFc treatment resulted in a significant increase in red bloodcell levels in sickle-cell mice (P≦0.001) in comparison control mice(sickle-cell mice administered vehicle alone).

FIG. 45 shows the effect of ActRIIB(L79D 25-131)-mFc on red blood celllevels, hematocrit levels, and hemoglobin levels in sickle-cell mice.Data are mean changes from baseline over 4 weeks (±SEM) vs. sickle-cellcontrol mice. ActRIIB(L79D 25-131)-mFc treatment resulted in asignificant increase in red blood cell levels, hematocrit levels, andhemoglobin levels in sickle-cell mice in comparison to control mice.

FIG. 46 shows the effect of ActRIIB(L79D 25-131)-mFc on various bloodparameters (i.e., mean corpuscular volume, red blood cell (RDC)distribution width, reticulocytes, and reactive oxygen species insickle-cell mice). Data are mean changes from baseline over 4 weeks(±SEM) vs. sickle-cell control mice. ActRIIB(L79D 25-131)-mFc treatmentresulted in a significant increase in mean corpuscular volume, red bloodcell (RDC) distribution width, reticulocytes, and reactive oxygenspecies in sickle-cell mice in comparison to control mice.

DETAIL DESCRIPTION OF THE INVENTION

1. Overview

The transforming growth factor-beta (TGF-beta) superfamily contains avariety of growth factors that share common sequence elements andstructural motifs. These proteins are known to exert biological effectson a large variety of cell types in both vertebrates and invertebrates.Members of the superfamily perform important functions during embryonicdevelopment in pattern formation and tissue specification and caninfluence a variety of differentiation processes, includingadipogenesis, myogenesis, chondrogenesis, cardiogenesis, hematopoiesis,neurogenesis, and epithelial cell differentiation. By manipulating theactivity of a member of the TGF-beta family, it is often possible tocause significant physiological changes in an organism. For example, thePiedmontese and Belgian Blue cattle breeds carry a loss-of-functionmutation in the GDF8 (also called myostatin) gene that causes a markedincrease in muscle mass. See, e.g., Grobet et al. (1997) Nat Genet.17(1):71-4. Furthermore, in humans, inactive alleles of GDF8 areassociated with increased muscle mass and, reportedly, exceptionalstrength. See, e.g., Schuelke et al. (2004) N Engl J Med, 350:2682-8.

TGF-β signals are mediated by heteromeric complexes of type I and typeII serine/threonine kinase receptors, which phosphorylate and activatedownstream SMAD proteins (e.g., SMAD proteins 1, 2, 3, 5, and 8) uponligand stimulation. See, e.g., Massagué (2000) Nat. Rev. Mol. Cell Biol.1:169-178. These type I and type II receptors are transmembraneproteins, composed of a ligand-binding extracellular domain withcysteine-rich region, a transmembrane domain, and a cytoplasmic domainwith predicted serine/threonine specificity. Type I receptors areessential for signaling. Type II receptors are required for bindingligands and for expression of Type I receptors. Type I and II activinreceptors form a stable complex after ligand binding, resulting inphosphorylation of Type I receptors by Type II receptors.

Two related Type II receptors (ActRII), ActRIIA and ActRIIB, have beenidentified as the Type II receptors for activins. See, e.g., Mathews andVale (1991) Cell 65:973-982; and Attisano et al. (1992) Cell 68: 97-108.Besides activins, ActRIIA and ActRIIB can biochemically interact withseveral other TGF-β family proteins including, for example, BMP6, BMP7,Nodal, GDF8, and GDF11. See, e.g., Yamashita et al. (1995) J. Cell Biol.130:217-226; Lee and McPherron (2001) Proc. Natl. Acad. Sci.98:9306-9311; Yeo and Whitman (2001) Mol. Cell 7: 949-957; and Oh et al.(2002) Genes Dev. 16:2749-54. ALK4 is the primary type I receptor foractivins, particularly for activin A, and ALK-7 may serve as a receptorfor other activins as well, particularly for activin B. In certainembodiments, the present disclosure relates to antagonizing a ligand ofan ActRII receptor (also referred to as an ActRII ligand) with one ormore inhibitor agents disclosed herein, particularly inhibitor agentsthat can antagonize GDF11 and/or GDF8.

Activins are dimeric polypeptide growth factors that belong to theTGF-beta superfamily. There are three principal activin forms (A. B, andAB) that are homo/heterodimers of two closely related β subunits(β_(A)β_(A), β_(B)β_(B), and β_(A)β_(B), respectively). The human genomealso encodes an activin C and an activin E, which are primarilyexpressed in the liver, and heterodimeric forms containing β_(C) orβ_(E) are also known.

In the TGF-beta superfamily, activins are unique and multifunctionalfactors that can stimulate hormone production in ovarian and placentalcells, support neuronal cell survival, influence cell-cycle progresspositively or negatively depending on cell type, and induce mesodermaldifferentiation at least in amphibian embryos. DePaolo et al. (1991)Proc Soc Ep Biol Med. 198:500-512; Dyson et al. (1997) Curr Biol.7:81-84; and Woodruff (1998) Biochem Pharmacol. 55:953-963. Moreover,erythroid differentiation factor (EDF) isolated from the stimulatedhuman monocytic leukemic cells was found to be identical to activin A.Murata et al. (1988) PNAS, 85:2434. It has been suggested that activin Apromotes erythropoiesis in the bone marrow. In several tissues, activinsignaling is antagonized by its related heterodimer, inhibin. Forexample, during the release of follicle-stimulating hormone (FSH) fromthe pituitary, activin promotes FSH secretion and synthesis, whileinhibin prevents FSH secretion and synthesis. Other proteins that mayregulate activin bioactivity and/or bind to activin include follistatin(FS), follistatin-related protein (FSRP, also known as FLRG or FSRL3),and α₂-macroglobulin.

As described herein, agents that bind to “activin A” are agents thatspecifically bind to the β_(A) subunit, whether in the context of anisolated β_(A) subunit or as a dimeric complex (e.g., a β_(A)β_(A)homodimer or a β_(A)β_(B) heterodimer). In the case of a heterodimercomplex (e.g., a β_(A)β_(B) heterodimer), agents that bind to “activinA” are specific for epitopes present within the β_(A) subunit, but donot bind to epitopes present within the non-β_(A) subunit of the complex(e.g., the Pa subunit of the complex). Similarly, agents disclosedherein that antagonize (inhibit) “activin A” are agents that inhibit oneor more activities as mediated by a β_(A) subunit, whether in thecontext of an isolated β_(A) subunit or as a dimeric complex (e.g., aβ_(A)β_(A) homodimer or a β_(A)β_(B) heterodimer). In the case ofβ_(A)β_(B) heterodimers, agents that inhibit “activin A” are agents thatspecifically inhibit one or more activities of the β_(A) subunit, but donot inhibit the activity of the non-β_(A) subunit of the complex (e.g.,the β_(B) subunit of the complex). This principle applies also to agentsthat bind to and/or inhibit “activin B”, “activin C”, and “activin E”.Agents disclosed herein that antagonize “activin AB” are agents thatinhibit one or more activities as mediated by the β_(A) subunit and oneor more activities as mediated by the Pa subunit.

Nodal proteins have functions in mesoderm and endoderm induction andformation, as well as subsequent organization of axial structures suchas heart and stomach in early embryogenesis. It has been demonstratedthat dorsal tissue in a developing vertebrate embryo contributespredominantly to the axial structures of the notochord and pre-chordalplate while it recruits surrounding cells to form non-axial embryonicstructures. Nodal appears to signal through both type I and type IIreceptors and intracellular effectors known as SMAD proteins. Studiessupport the idea that ActRIIA and ActRIIB serve as type II receptors forNodal. See, e.g., Sakuma et al. (2002) Genes Cells. 2002, 7:401-12. Itis suggested that Nodal ligands interact with their co-factors (e.g.,cripto) to activate activin type I and type II receptors, whichphosphorylate SMAD2. Nodal proteins are implicated in many eventscritical to the early vertebrate embryo, including mesoderm formation,anterior patterning, and left-right axis specification. Experimentalevidence has demonstrated that Nodal signaling activates pAR3-Lux, aluciferase reporter previously shown to respond specifically to activinand TGF-beta. However, Nodal is unable to induce pTlx2-Lux, a reporterspecifically responsive to bone morphogenetic proteins. Recent resultsprovide direct biochemical evidence that Nodal signaling is mediated byboth activin-TGF-beta pathway SMADs, SMAD2 and SMAD3. Further evidencehas shown that the extracellular cripto protein is required for Nodalsignaling, making it distinct from activin or TGF-beta signaling.

Growth and Differentiation Factor-8 (GDF8) is also known as myostatin.GDF8 is a negative regulator of skeletal muscle mass. GDF8 is highlyexpressed in the developing and adult skeletal muscle. The GDF8 nullmutation in transgenic mice is characterized by a marked hypertrophy andhyperplasia of the skeletal muscle. McPherron et al., Nature (1997)387:83-90. Similar increases in skeletal muscle mass are evident innaturally occurring mutations of GDF8 in cattle [see, e.g., Ashmore etal. (1974) Growth, 38:501-507; Swatland and Kieffer (1994) J. Anim. Sci.38:752-757; McPherron and Lee (1997) Proc. Natl. Acad. Sci. USA94:12457-12461; and Kambadur et al. (1997) Genome Res. 7:910-915] and,strikingly, in humans [see, e.g., Schuelke et al. (2004) N Engl J Med350:2682-8]. Studies have also shown that muscle wasting associated withHIV-infection in humans is accompanied by increases in GDF8 proteinexpression. See, e.g., Gonzalez-Cadavid et al. (1998) PNAS 95:14938-43.In addition, GDF8 can modulate the production of muscle-specific enzymes(e.g., creatine kinase) and modulate myoblast cell proliferation. See,e.g. international patent application publication no. WO 00/43781. TheGDF8 propeptide can noncovalently bind to the mature GDF8 domain dimer,inactivating its biological activity. See, e.g., Miyazono et al. (1988)J. Biol. Chem., 263: 6407-6415; Wakefield et al. (1988) J. Biol. Chem.,263: 7646-7654; and Brown et al. (1990) Growth Factors. 3: 35-43]. Otherproteins which bind to GDF8 or structurally related proteins and inhibittheir biological activity include follistatin, and potentially,follistatin-related proteins. See, e.g., Gamer et al. (1999) Dev. Biol.,208: 222-232.

Growth and Differentiation Factor-11 (GDF11), also known as BMP1, is asecreted protein. McPherron et al. (1999) Nat. Genet. 22: 260-264. GDF11is expressed in the tail bud, limb bud, maxillary and mandibular arches,and dorsal root ganglia during mouse development. See, e.g., Nakashimaet al. (1999) Mech. Dev. 80: 185-189. GDF11 plays a unique role inpatterning both mesodermal and neural tissues. See, e.g., Gamer et al.(1999) Dev Biol., 208:222-32. GDF11 was shown to be a negative regulatorof chondrogenesis and myogenesis in developing chick limb. See, e.g.,Gamer et al. (2001) Dev Biol. 229:407-20. The expression of GDF11 inmuscle also suggests its role in regulating muscle growth in a similarway to GDF8. In addition, the expression of GDF11 in brain suggests thatGDF11 may also possess activities that relate to the function of thenervous system. Interestingly, GDF11 was found to inhibit neurogenesisin the olfactory epithelium. See, e.g., Wu et al. (2003) Neuron.37:197-207.

Bone morphogenetic protein (BMP7), also called osteogenic protein-1(OP-1), is well known to induce cartilage and bone formation. Inaddition, BMP7 regulates a wide array of physiological processes. Forexample, BMP7 may be the osteoinductive factor responsible for thephenomenon of epithelial osteogenesis. It is also found that BMP7 playsa role in calcium regulation and bone homeostasis. Like activin, BMP7binds to Type II receptors, ActRIIA and ActRIIB. However, BMP7 andactivin recruit distinct Type I receptors into heteromeric receptorcomplexes. The major BMP7 Type I receptor observed was ALK2, whileactivin bound exclusively to ALK4 (ActRIIB). BMP7 and activin eliciteddistinct biological responses and activated different SMAD pathways.See, e.g., Macias-Silva et al. (1998) J Biol Chem. 273:25628-36.

As demonstrated herein, ActRII polypeptides (e.g., ActRIIA and ActRIIBpolypeptides) can be used to increase red blood cell levels in vivo. Incertain examples, it is shown that a GDF Trap polypeptide (specificallya variant ActRIIB polypeptide) is characterized by unique biologicalproperties in comparison to a corresponding sample of a wild-type(unmodified) ActRII polypeptide. This GDF Trap is characterized, inpart, by substantial loss of binding affinity for activin A, andtherefore significantly diminished capacity to antagonize activin Aactivity, but retains near wild-type levels of binding and inhibition ofGDF11. In vivo, the GDF Trap is more effective at increasing red bloodcell levels as compared to the wild-type ActRII polypeptide and hasbeneficial effects in patients with anemia including, e.g., patientswith sickle-cell disease and patients with thalassemia. For example, itis shown herein that GDF Trap therapy results in increased hemoglobinlevels in human patients that have thalassemia. In addition toimprovements in red blood cell parameters, certain thalassemia patientswere observed to have substantial resolution of a leg ulcer (which is acommon cutaneous complication of anemia, particularly in hemolyticanemias such as thalassemia and sickle-cell disease) during the courseof GDF Trap therapy. These data indicate a much broader use for ActRIIantagonists in the treatment of various complications of anemicdisorders beyond the positive effects on red blood cell parameters.

Accordingly, the methods of the present disclosure, in general, aredirected to the use of one or more ActRII antagonist agents describedherein, optionally in combination with one or more supportive therapies,to increase in red blood cell levels in a subject in need thereof, treator prevent an anemia in a subject in need thereof, and/or to treat orprevent one or more complications of anemia including, for example,ulcers, particularly cutaneous ulcers.

Furthermore, the data of the present disclosure indicates that theobserved biological activity of an ActRII polypeptide, with respect tored blood cell parameters and ulcers, is not dependent on activin Ainhibition. However, it is to be noted that the unmodified ActRIIBpolypeptide, which retains activin A binding, still demonstrates thecapacity to increase red blood cells in vivo. Furthermore, an ActRIIB orActRIIA polypeptide that retains activin A inhibition may be bettersuited in some applications, in comparison to a GDF Trap havingdiminished binding affinity for activin A, where more modest gains inred blood cell levels are desirable and/or where some level ofoff-target activity is acceptable (or even desirable).

It should be noted that hematopoiesis is a complex process, regulated bya variety of factors, including erythropoietin, G-CSF and ironhomeostasis. The terms “increase red blood cell levels” and “promote redblood cell formation” refer to clinically observable metrics, such ashematocrit, red blood cell counts, and hemoglobin measurements, and areintended to be neutral as to the mechanism by which such changes occur.

EPO is a glycoprotein hormone involved in the growth and maturation oferythroid progenitor cells into erythrocytes. EPO is produced by theliver during fetal life and by the kidney in adults. Decreasedproduction of EPO, which commonly occurs in adults as a consequence ofrenal failure, leads to anemia. EPO has been produced by geneticengineering techniques based on expression and secretion of the proteinfrom a host cell transfected with the EPO gene. Administration of suchrecombinant EPO has been effective in the treatment of anemia. Forexample, Eschbach et al. (1987, N Engl J Med 316:73) describe the use ofEPO to correct anemia caused by chronic renal failure.

Effects of EPO are mediated through its binding to, and activation of, acell surface receptor belonging to the cytokine receptor superfamily anddesignated the EPO receptor. The human and murine EPO receptors havebeen cloned and expressed. See, e.g., D'Andrea et al. (1989) Cell57:277; Jones et al. (1990) Blood 76:31; Winkelman et al. (1990) Blood76:24; and U.S. Pat. No. 5,278,065. The human EPO receptor gene encodesa 483 amino acid transmembrane protein comprising an extracellulardomain of approximately 224 amino acids and exhibits approximately 82%amino acid sequence identity with the murine EPO receptor. See, e.g.,U.S. Pat. No. 6,319,499. The cloned, full-length EPO receptor expressedin mammalian cells (66-72 kDa) binds EPO with an affinity (K_(D)=100-300nM) similar to that of the native receptor on erythroid progenitorcells. Thus, this form is thought to contain the main EPO bindingdeterminant and is referred to as the EPO receptor. By analogy withother closely related cytokine receptors, the EPO receptor is thought todimerize upon agonist binding. Nevertheless, the detailed structure ofthe EPO receptor, which may be a multimeric complex, and its specificmechanism of activation are not completely understood. See, e.g., U.S.Pat. No. 6,319,499.

Activation of the EPO receptor results in several biological effects.These include increased proliferation of immature erythroblasts,increased differentiation of immature erythroblasts, and decreasedapoptosis in erythroid progenitor cells. See, e.g., Liboi et al. (1993)Proc Natl Acad Sci USA 90:11351-11355; Koury et al. (1990) Science248:378-381. The EPO receptor signal transduction pathways mediatingproliferation and differentiation appear to be distinct. See, e.g.,Noguchi et al. (1988) Mol Cell Biol 8:2604; Patel et al. (1992) J BiolChem, 267:21300; and Liboi et al. (1993) Proc Natl Acad Sci USA90:11351-11355). Some results suggest that an accessory protein may berequired for mediation of the differentiation signal. See, e.g., Chibaet al. (1993) Nature 362:646; and Chiba et al. (1993) Proc Natl Acad SciUSA 90:11593. However, there is controversy regarding the role ofaccessory proteins in differentiation since a constitutively activatedform of the receptor can stimulate both proliferation anddifferentiation. See, e.g., Pharr et al. (1993) Proc Natl Acad Sci USA90:938.

EPO receptor activators include small moleculeerythropoiesis-stimulating agents (ESAs) as well as EPO-based compounds.An example of the former is a dimeric peptide-based agonist covalentlylinked to polyethylene glycol (proprietary name Hematide™ and Omontys®),which has shown erythropoiesis-stimulating properties in healthyvolunteers and in patients with both chronic kidney disease andendogenous anti-EPO antibodies. See, e.g., Stead et al. (2006) Blood108:1830-1834; and Macdougall et al. (2009) N Engl J Med 361:1848-1855.Other examples include nonpeptide-based ESAs. See, e.g., Qureshi et al.(1999) Proc Natl Acad Sci USA 96:12156-12161.

EPO receptor activators also include compounds that stimulateerythropoiesis indirectly, without contacting EPO receptor itself, byenhancing production of endogenous EPO. For example, hypoxia-inducibletranscription factors (HIFs) are endogenous stimulators of EPO geneexpression that are suppressed (destabilized) under normoxic conditionsby cellular regulatory mechanisms. Therefore, inhibitors of HIF prolylhydroxylase enzymes are being investigated for EPO-inducing activity invivo. Other indirect activators of EPO receptor include inhibitors ofGATA-2 transcription factor [see, e.g., Nakano et al. (2004) Blood104:4300-4307], which tonically inhibits EPO gene expression, andinhibitors of hemopoietic cell phosphatase (HCP or SHP-1), whichfunctions as a negative regulator of EPO receptor signal transduction[see, e.g., Klingmuller et al. (1995) Cell 80:729-738.

The terms used in this specification generally have their ordinarymeanings in the art, within the context of this disclosure and in thespecific context where each term is used. Certain terms are discussedbelow or elsewhere in the specification, to provide additional guidanceto the practitioner in describing the compositions and methods of thedisclosure and how to make and use them. The scope or meaning of any useof a term will be apparent from the specific context in which they areused.

“Homologous,” in all its grammatical forms and spelling variations,refers to the relationship between two proteins that possess a “commonevolutionary origin,” including proteins from superfamilies in the samespecies of organism, as well as homologous proteins from differentspecies of organism. Such proteins (and their encoding nucleic acids)have sequence homology, as reflected by their sequence similarity,whether in terms of percent identity or by the presence of specificresidues or motifs and conserved positions.

The term “sequence similarity,” in all its grammatical forms, refers tothe degree of identity or correspondence between nucleic acid or aminoacid sequences that may or may not share a common evolutionary origin.

However, in common usage and in the instant application, the term“homologous,” when modified with an adverb such as “highly.” may referto sequence similarity and may or may not relate to a commonevolutionary origin.

“Percent (%) sequence identity” with respect to a reference polypeptide(or nucleotide) sequence is defined as the percentage of amino acidresidues (or nucleic acids) in a candidate sequence that are identicalto the amino acid residues (or nucleic acids) in the referencepolypeptide (nucleotide) sequence, after aligning the sequences andintroducing gaps, if necessary, to achieve the maximum percent sequenceidentity, and not considering any conservative substitutions as part ofthe sequence identity. Alignment for purposes of determining percentamino acid sequence identity can be achieved in various ways that arewithin the skill in the art, for instance, using publicly availablecomputer software such as BLAST, BLAST-2, ALIGN or Megalign (DNASTAR)software. Those skilled in the art can determine appropriate parametersfor aligning sequences, including any algorithms needed to achievemaximal alignment over the full length of the sequences being compared.For purposes herein, however, % amino acid (nucleic acid) sequenceidentity values are generated using the sequence comparison computerprogram ALIGN-2. The ALIGN-2 sequence comparison computer program wasauthored by Genentech, Inc., and the source code has been filed withuser documentation in the U.S. Copyright Office, Washington D.C., 20559,where it is registered under U.S. Copyright Registration No. TXU510087.The ALIGN-2 program is publicly available from Genentech, Inc., SouthSan Francisco, Calif., or may be compiled from the source code. TheALIGN-2 program should be compiled for use on a UNIX operating system,including digital UNIX V4.0D. All sequence comparison parameters are setby the ALIGN-2 program and do not vary.

As used herein “does not substantially bind to X” is intended to meanthat an agent has a K_(D) that is greater than about 10⁻⁷, 10⁻⁶, 10⁻⁵,10⁻⁴ or greater (e.g., no detectable binding by the assay used todetermine the K_(D)) for “X”.

2. ActRII Antagonist

The data presented herein demonstrates that antagonists (inhibitors) ofActRII (e.g., antagonist of ActRIIA and/or ActRIIB SMAD 2/3 and/or SMAD1/5/8 signaling) can be used in increasing red blood cell levels invivo. In particular, such ActRII antagonists are shown herein to beeffective in treating various anemias as well as various complications(e.g., disorders/conditions) of anemia including, for example, cutaneousulcers. Accordingly, the present disclosure provides, in part, variousActRII antagonist agents that can be used, alone or in combination withone or more erythropoiesis stimulating agents (e.g., EPO) or othersupportive therapies [e.g., treatment with hydroxyurea, bloodtransfusion, iron chelation therapy, and/or pain management (e.g.,treatment with one or more of opioid analgesic agents, non-steroidalanti-inflammatory drugs, and/or corticosteroids)], to treat or preventan anemia in a subject in need thereof and/or to treat or prevent acutaneous ulcer in a patient that has anemia.

In certain embodiments, the ActRII antagonists to be used in accordancewith the methods disclosed herein are GDF-ActRII antagonists (e.g.,antagonists of GDF-mediated ActRIIA and/or ActRIIB signalingtransduction, such as SMAD 2/3 signaling), particularly GDF11- and/orGDF8-mediated ActRII signaling. In some embodiments, ActRII antagonistsof the present disclosure are soluble ActRII polypeptides (e.g., solubleActRIIA and ActRIIB polypeptides) and GDF Trap polypeptides, such asActRIIA-Fc fusion proteins, ActRIIB-Fc fusion proteins, and GDF Trap-Fcfusion proteins.

Although soluble ActRII polypeptides and GDF Trap polypeptides of thedisclosure may affect red blood cell levels and/or cutaneous ulcersthrough a mechanism other than GDF (e.g. GDF11 and/or GDF8) antagonism[e.g., GDF11 and/or GDF8 inhibition may be an indicator of the tendencyof an agent to inhibit the activities of a spectrum of additionalagents, including, perhaps, other members of the TGF-beta superfamily(e.g., activin B, activin C, activin E, BMP6, BMP7, and/or Nodal) andsuch collective inhibition may lead to the desired effect on, e.g.,hematopoiesis], other types of GDF-ActRII antagonist are expected to beuseful including, for example, anti-GDF11 antibodies; anti-GDF8antibodies; anti-ActRIIA antibodies; anti-ActRIIB antibodies; antisense,RNAi, or ribozyme nucleic acids that inhibit the production of one ormore of GDF11, GDF8, ActRIIA, and/or ActRIIB; and other inhibitors(e.g., small molecule inhibitors) of one or more of GDF11, GDF8,ActRIIA, and/or ActRIIB, particularly agents that disrupt GDF11- and/orGDF8-ActRIIA binding and/or GDF11- and/or GDF8-ActRIIB binding as wellas agents that inhibit expression of one or more of GDF11, GDF8,ActRIIA, and/or ActRIIB. Optionally, GDF-ActRII antagonists of thepresent disclosure may bind to and/or inhibit the activity (orexpression) of other ActRII ligands including, for example, activin A,activin AB, activin B, activin C, activin E, BMP6, BMP7, and/or Nodal.Optionally, a GDF-ActRII antagonist of the present disclosure may beused in combination with at least one additional ActRII antagonist agentthat binds to and/or inhibits the activity (or expression) of one ormore additional ActRII ligands including, for example, activin A,activin AB, activin B, activin C, activin E, BMP6, BMP7, and/or Nodal.In some embodiments, ActRII antagonists to be used in accordance withthe methods disclosed herein do not substantially bind to and/or inhibitactivin A (e.g., activin A-mediated activation of ActRIIA and/or ActRIIBsignaling transduction, such as SMAD 2/3 signaling).

A. ActRII polypeptides and GDF Traps

In certain aspects, the present disclosure relates to ActRIIpolypeptides. In particular, the disclosure provides methods of usingActRII polypeptides to, e.g., treat or prevent an anemia in a subject inneed thereof and/or treat or prevent one or more complication of anemiaincluding, for example, cutaneous ulcers. As used herein the term“ActRII” refers to the family of type II activin receptors. This familyincludes both the activin receptor type IIA and the activin receptortype IIB. In some embodiments, the disclosure provides methods of usingActRII polypeptides to treat an anemia in a subject in need thereofand/or treat one or more complications of anemia including, for example,cutaneous ulcers, in a subject having anemia. In some embodiments, thedisclosure provides methods of using ActRII polypeptides to prevent ananemia in a subject in need thereof and/or prevent one or morecomplications of anemia including, for example, cutaneous ulcers in asubject having anemia. In some embodiments, the ActRII polypeptides areActRIIA polypeptides. In some embodiments, the ActRII polypeptides areActRIIB polypeptides.

As used herein, the term “ActRIIB” refers to a family of activinreceptor type IIB (ActRIIB) proteins from any species and variantsderived from such ActRIIB proteins by mutagenesis or other modification.Reference to ActRIIB herein is understood to be a reference to any oneof the currently identified forms. Members of the ActRIIB family aregenerally transmembrane proteins, composed of a ligand-bindingextracellular domain comprising a cysteine-rich region, a transmembranedomain, and a cytoplasmic domain with predicted serine/threonine kinaseactivity.

The term “ActRIIB polypeptide” includes polypeptides comprising anynaturally occurring polypeptide of an ActRIIB family member as well asany variants thereof (including mutants, fragments, fusions, andpeptidomimetic forms) that retain a useful activity. Examples of suchvariant ActRIIA polypeptides are provided throughout the presentdisclosure as well as in International Patent Application PublicationNo. WO 2006/012627, which is incorporated herein by reference in itsentirety. Optionally, ActRIIB polypeptides of the present disclosure canbe used to increase red blood cell levels in a subject. Numbering ofamino acids for all ActRIIB-related polypeptides described herein isbased on the numbering of the human ActRIIB precursor protein sequenceprovided below (SEQ ID NO: 1), unless specifically designated otherwise.

The human ActRIIB precursor protein sequence is as follows:

(SEQ ID NO: 1) 1 MTAPWVALAL LWGSLCAGS+EE G RGEAETRECI YYNANWELER T NNQSGLERCE 51 GEQDKRLHCY ASWR N SSGTI ELVKKGCWLD DFNCYDRQEC VATEENPQVY101 FCCCEGNFCN ERFTHLPEAG GPEVTYEPPP TAPTLLTVLA YSLLPIGGLS 151LIVLLAFWMY RHRKPPYGHV DIHEDPGPPP PSPLVGLKPL QLLEIKARGR 201FGCVWKAQLM NDFVAVKIFP LQDKQSWQSE REIFSTPGMK HENLLQFIAA 251EKRGSNLEVE LWLITAFHDK GSLTDYLKGN IITWNELCHV AETMSRGLSY 301LHEDVPWCRG EGHKPSIAHR DFKSKNVLLK SDLTAVLADF GLAVRFEPGK 351PPGDTHGQVG TRRYMAPEVL EGAINFQRDA FLRIDMYAMG LVLWELVSRC 401KAADGPVDEY MLPFEEEIGQ HPSLEELQEV VVHKKMRPTI KDHWLKHPGL 451AQLCVTIEEC WDHDAEARLS AGCVEERVSL IRRSVNGTTS DCLVSLVTSV 501 TNVDLPPKES SI

The signal peptide is indicated with single underlined; theextracellular domain is indicated in bold font; and the potential,endogenous N-linked glycosylation sites are indicated with doubleunderline.

The processed soluble (extracellular) human ActRIIB polypeptide sequenceis as follows:

(SEQ ID NO: 2) GRGEAETRECIYYNANWELERTNQSGLERCEGEQDKRLHCYASWRNSSGTIELVKKGCWLDDFNCYDRQECVATEENPQVYFCCCEGNFCNERFTHLPEA GGPEVTYEPPPTAPT.

In some embodiments, the protein may be produced with an “SGR . . . ”sequence at the N-terminus. The C-terminal “tail” of the extracellulardomain is indicated by single underline. The sequence with the “tail”deleted (a Δ15 sequence) is as follows:

(SEQ ID NO: 3) GRGEAETRECIYYNANWELERTNQSGLERCEGEQDKRLHCYASWRNSSGTIELVKKGCWLDDFNCYDRQECVATEENPQVYFCCCEGNFCNERFTHLPE A.

A form of ActRIIB with an alanine at position 64 of SEQ ID NO:1 (A64) isalso reported in the literature. See, e.g., Hilden et al. (1994) Blood,83(8): 2163-2170. Applicants have ascertained that an ActRIIB-Fc fusionprotein comprising an extracellular domain of ActRIIB with the A64substitution has a relatively low affinity for activin and GDF11. Bycontrast, the same ActRIIB-Fc fusion protein with an arginine atposition 64 (R64) has an affinity for activin and GDF11 in the lownanomolar to high picomolar range. Therefore, sequences with an R64 areused as the “wild-type” reference sequence for human ActRIIB in thisdisclosure.

The form of ActRIIB with an alanine at position 64 is as follows:

(SEQ ID NO: 4) 1 MTAPWVALAL LWGSLCAGS G RGEAETRECI YYNANWELER TNQSGLERCE51 GEQDKRLHCY ASWANSSGTI ELVKKGCWLD DFNCYDRQEC VATEENPQVY 101FCCCEGNFCN ERFTHLPEAG GPEVTYEPPP TAPTLLTVLA YSLLPIGGLS 151LIVLLAFWMY RHRKPPYGHV DIHEDPGPPP PSPLVGLKPL QLLEIKARGR 201FGCVWKAQLM NDFVAVKIFP LQDKQSWQSE REIFSTPGMK HENLLQFIAA 251EKRGSNLEVE LWLITAFHDK GSLTDYLKGN IITWNELCHV AETMSRGLSY 301LHEDVPWCRG EGHKPSIAHR DFKSKNVLLK SDLTAVLADF GLAVRFEPGK 351PPGDTHGQVG TRRYMAPEVL EGAINFQRDA FLRIDMYAMG LVLWELVSRC 401KAADGPVDEY MLPFEEEIGQ HPSLEELQEV VVHKKMRPTI KDHWLKHPGL 451AQLCVTIEEC WDHDAEARLS AGCVEERVSL IRRSVNGTTS DCLVSLVTSV 501TNVDLPPKES SI.

The signal peptide is indicated by single underline and theextracellular domain is indicated by bold font.

The processed soluble (extracellular) ActRIIB polypeptide sequence ofthe alternative A64 form is as follows:

(SEQ ID NO: 5) GRGEAETRECIYYNANWELERTNQSGLERCEGEQDKRLHCYASWANSSGTIELVKKGCWLDDFNCYDRQECVATEENPQVYFCCCEGNFCNERFTHLPEA GGPEVTYEPPPTAPT.

In some embodiments, the protein may be produced with an “SGR . . . ”sequence at the N-terminus. The C-terminal “tail” of the extracellulardomain is indicated by single underline. The sequence with the “tail”deleted (a Δ15 sequence) is as follows:

(SEQ ID NO: 6) GRGEAETRECIYYNANWELERTNQSGLERCEGEQDKRLHCYASWANSSGTIELVKKGCWLDDFNCYDRQECVATEENPQVYFCCCEGNFCNERFTHLPE A.

The nucleic acid sequence encoding a human ActRIIB precursor protein isshown below (SEQ ID NO:7), consisting of nucleotides 25-1560 of GenbankReference Sequence NM_001106.3, which encode amino acids 1-513 of theActRIIB precursor. The sequence as shown provides an arginine atposition 64 and may be modified to provide an alanine instead. Thesignal sequence is underlined.

(SEQ ID NO: 7) 1 ATGACGGCGC CCTGGGTGGC CCTCGCCCTC CTCTGGGGAT CGCTGTGCGC51 CGGCTCTGGG CGTGGGGAGG CTGAGACACG GGAGTGCATC TACTACAACG 101CCAACTGGGA GCTGGAGCGC ACCAACCAGA GCGGCCTGGA GCGCTGCGAA 151GGCGAGCAGG ACAAGCGGCT GCACTGCTAC GCCTCCTGGC GCAACAGCTC 201TGGCACCATC GAGCTCGTGA AGAAGGGCTG CTGGCTAGAT GACTTCAACT 251GCTACGATAG GCAGGAGTGT GTGGCCACTG AGGAGAACCC CCAGGTGTAC 301TTCTGCTGCT GTGAAGGCAA CTTCTGCAAC GAACGCTTCA CTCATTTGCC 351AGAGGCTGGG GGCCCGGAAG TCACGTACGA GCCACCCCCG ACAGCCCCCA 401CCCTGCTCAC GGTGCTGGCC TACTCACTGC TGCCCATCGG GGGCCTTTCC 451CTCATCGTCC TGCTGGCCTT TTGGATGTAC CGGCATCGCA AGCCCCCCTA 501CGGTCATGTG GACATCCATG AGGACCCTGG GCCTCCACCA CCATCCCCTC 551TGGTGGGCCT GAAGCCACTG CAGCTGCTGG AGATCAAGGC TCGGGGGCGC 601TTTGGCTGTG TCTGGAAGGC CCAGCTCATG AATGACTTTG TAGCTGTCAA 651GATCTTCCCA CTCCAGGACA AGCAGTCGTG GCAGAGTGAA CGGGAGATCT 701TCAGCACACC TGGCATGAAG CACGAGAACC TGCTACAGTT CATTGCTGCC 751GAGAAGCGAG GCTCCAACCT CGAAGTAGAG CTGTGGCTCA TCACGGCCTT 801CCATGACAAG GGCTCCCTCA CGGATTACCT CAAGGGGAAC ATCATCACAT 851GGAACGAACT GTGTCATGTA GCAGAGACGA TGTCACGAGG CCTCTCATAC 901CTGCATGAGG ATGTGCCCTG GTGCCGTGGC GAGGGCCACA AGCCGTCTAT 951TGCCCACAGG GACTTTAAAA GTAAGAATGT ATTGCTGAAG AGCGACCTCA 1001CAGCCGTGCT GGCTGACTTT GGCTTGGCTG TTCGATTTGA GCCAGGGAAA 1051CCTCCAGGGG ACACCCACGG ACAGGTAGGC ACGAGACGGT ACATGGCTCC 1101TGAGGTGCTC GAGGGAGCCA TCAACTTCCA GAGAGATGCC TTCCTGCGCA 1151TTGACATGTA TGCCATGGGG TTGGTGCTGT GGGAGCTTGT GTCTCGCTGC 1201AAGGCTGCAG ACGGACCCGT GGATGAGTAC ATGCTGCCCT TTGAGGAAGA 1251GATTGGCCAG CACCCTTCGT TGGAGGAGCT GCAGGAGGTG GTGGTGCACA 1301AGAAGATGAG GCCCACCATT AAAGATCACT GGTTGAAACA CCCGGGCCTG 1351GCCCAGCTTT GTGTGACCAT CGAGGAGTGC TGGGACCATG ATGCAGAGGC 1401TCGCTTGTCC GCGGGCTGTG TGGAGGAGCG GGTGTCCCTG ATTCGGAGGT 1451CGGTCAACGG CACTACCTCG GACTGTCTCG TTTCCCTGGT GACCTCTGTC 1501ACCAATGTGG ACCTGCCCCC TAAAGAGTCA AGCATC.

A nucleic acid sequence encoding processed soluble (extracellular) humanActRIIB polypeptide is as follows (SEQ ID NO:8). The sequence as shownprovides an arginine at position 64 and may be modified to provide analanine instead.

(SEQ ID NO: 8) 1 GGGCGTGGGG AGGCTGAGAC ACGGGAGTGC ATCTACTACA ACGCCAACTG51 GGAGCTGGAG CGCACCAACC AGAGCGGCCT GGAGCGCTGC GAAGGCGAGC 101 AGGACAAGCGGCTGCACTGC TACGCCTCCT GGCGCAACAG CTCTGGCACC 151 ATCGAGCTCG TGAAGAAGGGCTGCTGGCTA GATGACTTCA ACTGCTACGA 201 TAGGCAGGAG TGTGTGGCCA CTGAGGAGAACCCCCAGGTG TACTTCTGCT 251 GCTGTGAAGG CAACTTCTGC AACGAACGCT TCACTCATTTGCCAGAGGCT 301 GGGGGCCCGG AAGTCACGTA CGAGCCACCC CCGACAGCCC CCACC.

In certain embodiments, the present disclosure relates to ActRIIApolypeptides. As used herein, the term “ActRIIA” refers to a family ofactivin receptor type IIA (ActRIIA) proteins from any species andvariants derived from such ActRIIA proteins by mutagenesis or othermodification. Reference to ActRIIA herein is understood to be areference to any one of the currently identified forms. Members of theActRIIA family are generally transmembrane proteins, composed of aligand-binding extracellular domain comprising a cysteine-rich region, atransmembrane domain, and a cytoplasmic domain with predictedserine/threonine kinase activity.

The term “ActRIIA polypeptide” includes polypeptides comprising anynaturally occurring polypeptide of an ActRIIA family member as well asany variants thereof (including mutants, fragments, fusions, andpeptidomimetic forms) that retain a useful activity. Examples of suchvariant ActRIIA polypeptides are provided throughout the presentdisclosure as well as in International Patent Application PublicationNo. WO 2006/012627, which is incorporated herein by reference in itsentirety. Optionally, ActRIIA polypeptides of the present disclosure canbe used to increase red blood cell levels in a subject. Numbering ofamino acids for all ActRIIA-related polypeptides described herein isbased on the numbering of the human ActRIIA precursor protein sequenceprovided below (SEQ ID NO:9), unless specifically designated otherwise.

The human ActRIIA precursor protein sequence is as follows:

(SEQ ID NO: 9) 1 MGAAAKLAFA VFLISCSSGA ILGRSETQEC LFFN ANWEKD RTNQTGVEPC51 YGDKDKRRHC FATWKN ISGS IEIVKQGCWL DDINCYDRTD CVEKKDSPEV 101YFCCCEGNMC NEKFSYFPEM EVTQPTSNPV TPKPPYYNIL LYSLVPLMLI 151 AGIVICAFWVYRHHKMAYPP VLVPTQDPGP PPPSPLLGLK PLQLLEVKAR 201 GRFGCVWKAQ LLNEYVAVKIFPIQDKQSWQ NEYEVYSLPG MKHENILQFI 251 GAEKRGTSVD VDLWLITAFH EKGSLSDFLKANVVSWNELC HIAETMARGL 301 AYLHEDIPGL KDGHKPAISH RDIKSKNVLL KNNLTACIADFGLALKFEAG 351 KSAGDTHGQV GTRRYMAPEV LEGAINFQRD AFLRIDMYAM GLVLWELASR401 CTAADGPVDE YMLPFEEEIG QHPSLEDMQE VVVHKKKRPV LRDYWQKHAG 451MAMLCETIEE CWDHDAEARL SAGCVGERIT QMQRLTNIIT TEDIVTVVTM 501 VTNVDFPPKESSL

The signal peptide is indicated by single underline; the extracellulardomain is indicated in bold font; and the potential, endogenous N-linkedglycosylation sites are indicated by double underline.

The processed soluble (extracellular) human ActRIIA polypeptide sequenceis as follows:

(SEQ ID NO: 10) ILGRSETQECLFFNANWEKDRTNQTGVEPCYGDKDKRRHCFATWKNISGSIEIVKQGCWLDDINCYDRTDCVEKKDSPEVYFCCCEGNMCNEKFSY FPEMEVTQPTSNPVTPKPP

The C-terminal “tail” of the extracellular domain is indicated by singleunderline. The sequence with the “tail” deleted (a Δ15 sequence) is asfollows:

(SEQ ID NO: 11) ILGRSETQECLFFNANWEKDRTNQTGVEPCYGDKDKRRHCFATWKNISGSIEIVKQGCWLDDINCYDRTDCVEKKDSPEVYFCCCEGNMCNEKFSY FPEM

The nucleic acid sequence encoding human ActRIIA precursor protein isshown below (SEQ ID NO:12), as follows nucleotides 159-1700 of GenbankReference NM_001616.4. The signal sequence is underlined.

(SEQ ID NO: 12) 1 atgggagctg ctgcaaagtt ggcgtttgcc gtctttctta tctcctgttc51 ttcaggtgct atacttggta gatcagaaac tcaggagtgt cttttcttta 101 atgctaattgggaaaaagac agaaccaatc aaactggtgt tgaaccgtgt 151 tatggtgaca aagataaacggcggcattgt tttgctacct ggaagaatat 201 ttctggttcc attgaaatag tgaaacaaggttgttggctg gatgatatca 251 actgctatga caggactgat tgtgtagaaa aaaaagacagccctgaagta 301 tatttttgtt gctgtgaggg caatatgtgt aatgaaaagt tttcttattt351 tccggagatg gaagtcacac agcccacttc aaatccagtt acacctaagc 401caccctatta caacatcctg ctctattcct tggtgccact tatgttaatt 451 gcggggattgtcatttgtgc attttgggtg tacaggcatc acaagatggc 501 ctaccctcct gtacttgttccaactcaaga cccaggacca cccccacctt 551 ctccattact aggtttgaaa ccactgcagttattagaagt gaaagcaagg 601 ggaagatttg gttgtgtctg gaaagcccag ttgcttaacgaatatgtggc 651 tgtcaaaata tttccaatac aggacaaaca gtcatggcaa aatgaatacg701 aagtctacag tttgcctgga atgaagcatg agaacatatt acagttcatt 751ggtgcagaaa aacgaggcac cagtgttgat gtggatcttt ggctgatcac 801 agcatttcatgaaaagggtt cactatcaga ctttcttaag gctaatgtgg 851 tctcttggaa tgaactgtgtcatattgcag aaaccatggc tagaggattg 901 gcatatttac atgaggatat acctggcctaaaagatggcc acaaacctgc 951 catatctcac agggacatca aaagtaaaaa tgtgctgttgaaaaacaacc 1001 tgacagcttg cattgctgac tttgggttgg ccttaaaatt tgaggctggc1051 aagtctgcag gcgataccca tggacaggtt ggtacccgga ggtacatggc 1101tccagaggta ttagagggtg ctataaactt ccaaagggat gcatttttga 1151 ggatagatatgtatgccatg ggattagtcc tatgggaact ggcttctcgc 1201 tgtactgctg cagatggacctgtagatgaa tacatgttgc catttgagga 1251 ggaaattggc cagcatccat ctcttgaagacatgcaggaa gttgttgtgc 1301 ataaaaaaaa gaggcctgtt ttaagagatt attggcagaaacatgctgga 1351 atggcaatgc tctgtgaaac cattgaagaa tgttgggatc acgacgcaga1401 agccaggtta tcagctggat gtgtaggtga aagaattacc cagatgcaga 1451gactaacaaa tattattacc acagaggaca ttgtaacagt ggtcacaatg 1501 gtgacaaatgttgactttcc tcccaaagaa tctagtcta

The nucleic acid sequence encoding processed soluble (extracellularhuman ActRIIA polypeptide is as follows:

(SEQ ID NO: 13) 1 atacttggta gatcagaaac tcaggagtgt cttttcttta atgctaattg51 ggaaaaagac agaaccaatc aaactggtgt tgaaccgtgt tatggtgaca 101 aagataaacggcggcattgt tttgctacct ggaagaatat ttctggttcc 151 attgaaatag tgaaacaaggttgttggctg gatgatatca actgctatga 201 caggactgat tgtgtagaaa aaaaagacagccctgaagta tatttttgtt 251 gctgtgaggg caatatgtgt aatgaaaagt tttcttattttccggagatg 301 gaagtcacac agcccacttc aaatccagtt acacctaagc caccc.

An alignment of the amino acid sequences of human ActRIIB solubleextracellular domain and human ActRIIA soluble extracellular domain areillustrated in FIG. 1. This alignment indicates amino acid residueswithin both receptors that are believed to directly contact ActRIIligands. FIG. 2 depicts a multiple sequence alignment of variousvertebrate ActRIIB proteins and human ActRIIA. From these alignments isit possible to predict key amino acid positions within theligand-binding domain that are important for normal ActRII-ligandbinding activities as well as to predict amino acid positions that arelikely to be tolerant to substitution without significantly alteringnormal ActRII-ligand binding activities.

In other aspects, the present disclosure relates to GDF Trappolypeptides (also referred to as “GDF Traps”). In particular, thedisclosure provides methods of using GDF Trap polypeptides to, e.g.,treat or prevent an anemia in a subject in need thereof, treat sicklecell disease in a subject in need thereof and/or treat or prevent one ormore complications of anemia including, for example, cutaneous ulcers.In some embodiments, the disclosure provides methods of using GDF Trappolypeptides to treat an anemia in a subject in need thereof and/ortreat one or more complications of anemia including, for example,cutaneous ulcers, in a subject having anemia. In some embodiments, thedisclosure provides methods of using GDF Trap polypeptides to prevent ananemia in a subject in need thereof and/or prevent one or morecomplications of anemia including, for example, cutaneous ulcers, in asubject having anemia.

In some embodiments, GDF Traps of the present disclosure are soluble,variant ActRII polypeptides (e.g., ActRIIA and ActRIIB polypeptides)that comprise one or more mutations (e.g., amino acid additions,deletions, substitutions, and combinations thereof) in the extracellulardomain (also referred to as the ligand-binding domain) of an ActRIIpolypeptide (e.g., a “wild-type” ActRII polypeptide) such that thevariant ActRII polypeptide has one or more altered ligand-bindingactivities than the corresponding wild-type ActRII polypeptide. In someembodiments, GDF Trap polypeptides of the present disclosure retain atleast one similar activity as a corresponding wild-type ActRIIpolypeptide (e.g., an ActRIIA or ActRIIB polypeptide). For example, aGDF Trap may bind to and/or inhibit (e.g. antagonize) the function ofone or more ActRII ligands (e.g., inhibit ActRII ligand-mediatedactivation of the ActRIIA and/or ActRIIB signaling transduction, such asSMAD 2/3 and/or SMAD 1/5/8 signaling pathway). In some embodiments, GDFTraps of the present disclosure bind to and/or inhibit one or more ofactivin A, activin B, activin AB, activin C, activin E, Nodal, GDF8,GDF11, BMP6 and/or BMP7).

In certain embodiments, GDF Trap polypeptides of the disclosure haveelevated binding affinity for one or more specific ActRII ligands (e.g.,GDF8, GDF11, BMP6, Nodal, and/or BMP7). In other embodiments, GDF Trappolypeptides of the disclosure have decreased binding affinity for oneor more specific ActRII ligands (e.g., activin A, activin B, activin AB,activin C, and/or activin E). In still other embodiments, GDF Trappolypeptides of the disclosure have elevated binding affinity for one ormore specific ActRII ligands and decreased binding affinity for one ormore different/other ActRII ligands. Accordingly, the present disclosureprovides GDF Trap polypeptides that have an altered binding specificityfor one or more ActRII ligands.

In certain embodiments, GDF Traps of the present disclosure are designedto preferentially bind to and antagonize GDF11 and/or GDF8 (also knownas myostatin), e.g., in comparison to a wild-type ActRII polypeptide.Optionally, such GDF11 and/or GDF8-binding Traps may further bind toand/or antagonize one or more of Nodal, GDF8, GDF11, BMP6 and/or BMP7.Optionally, such GDF11 and/or GDF8-binding Traps may further bind toand/or antagonize one or more of activin B, activin C, activin E, Nodal,GDF8, GDF11, BMP6 and/or BMP7. Optionally, such GDF11 and/orGDF8-binding Traps may further bind to and/or antagonize one or more ofactivin A, activin A/B, activin B, activin C, activin E, Nodal, GDF8,GDF11, BMP6 and/or BMP7. In certain embodiments, GDF Traps of thepresent disclosure have diminished binding affinity for activins (e.g.,activin A, activin A/B, activin B, activin C, activin E), e.g., incomparison to a wild-type ActRII polypeptide. In certain embodiments, aGDF Trap polypeptide of the present disclosure has diminished bindingaffinity for activin A.

For example, the disclosure provides GDF Trap polypeptides thatpreferentially bind to and/or antagonize GDF8/GDF11 relative to activinA. As demonstrated by the Examples of the disclosure, such GDF Trappolypeptides are more potent activators of erythropoiesis in vivo incomparison to ActRII polypeptides that retain high binding affinity foractivin A. Furthermore, these non-activin A-binding GDF Trapspolypeptides demonstrate decreased effects on other tissues. Therefore,such GDF Traps may be useful for increasing red blood cell levels in asubject while reducing potential off-target effects associated withbinding/antagonizing activin A. However, such selective GDF Trappolypeptides may be less desirable in some applications wherein moremodest gains in red blood cell levels may be needed for therapeuticeffect and wherein some level of off-target effect is acceptable (oreven desirable).

Amino acid residues of the ActRIIB proteins (e.g., E39, K55, Y60, K74,W78, L79, D80, and F101) are in the ActRIIB ligand-binding pocket andhelp mediate binding to its ligands including, for example, activin A,GDF11, and GDF8. Thus the present disclosure provides GDF Trappolypeptides comprising an altered-ligand binding domain (e.g., aGDF8/GDF11-binding domain) of an ActRIIB receptor which comprises one ormore mutations at those amino acid residues.

Optionally, the altered ligand-binding domain can have increasedselectivity for a ligand such as GDF11 and/or GDF8 relative to awild-type ligand-binding domain of an ActRIIB receptor. To illustrate,one or more mutations may be selected that increase the selectivity ofthe altered ligand-binding domain for GDF11 and/or GDF8 over one or moreactivins (activin A, activin B, activin AB, activin C, and/or activinA), particularly activin A. Optionally, the altered ligand-bindingdomain has a ratio of K_(d) for activin binding to K_(d) for GDF11and/or GDF8 binding that is at least 2-, 5-, 10-, 20-, 50-, 100- or even1000-fold greater relative to the ratio for the wild-type ligand-bindingdomain. Optionally, the altered ligand-binding domain has a ratio ofIC₅₀ for inhibiting activin to IC₅₀ for inhibiting GDF11 and/or GDF8that is at least 2-, 5-, 10-, 20-, 50-, 100- or even 1000-fold greaterrelative to the wild-type ligand-binding domain. Optionally, the alteredligand-binding domain inhibits GDF11 and/or GDF8 with an IC₅₀ at least2-, 5-, 10-, 20-, 50-, 100- or even 1000-times less than the IC₅₀ forinhibiting activin.

As a specific example, the positively-charged amino acid residue Asp(D80) of the ligand-binding domain of ActRIIB can be mutated to adifferent amino acid residue to produce a GDF Trap polypeptide thatpreferentially binds to GDF8, but not activin. Preferably, the D80residue with respect to SEQ ID NO: 1 is changed to an amino acid residueselected from the group consisting of: an uncharged amino acid residue,a negative amino acid residue, and a hydrophobic amino acid residue. Asa further specific example, the hydrophobic residue L79 of SEQ ID NO: 1can be altered to confer altered activin-GDF11/GDF8 binding properties.For example, an L79P substitution reduces GDF11 binding to a greaterextent than activin binding. In contrast, replacement of L79 with anacidic amino acid [an aspartic acid or glutamic acid; an L79D or an L79Esubstitution] greatly reduces activin A binding affinity while retainingGDF11 binding affinity. In exemplary embodiments, the methods describedherein utilize a GDF Trap polypeptide which is a variant ActRIIBpolypeptide comprising an acidic amino acid (e.g., D or E) at theposition corresponding to position 79 of SEQ ID NO: 1, optionally incombination with one or more additional amino acid substitutions,additions, or deletions.

As will be recognized by one of skill in the art, most of the describedmutations, variants or modifications described herein may be made at thenucleic acid level or, in some cases, by post-translational modificationor chemical synthesis. Such techniques are well known in the art andsome of which are described herein.

In certain embodiments, the present disclosure relates to ActRIIpolypeptides (ActRIIA and ActRIIB polypeptides) which are soluble ActRIIpolypeptides. As described herein, the term “soluble ActRII polypeptide”generally refers to polypeptides comprising an extracellular domain ofan ActRII protein. The term “soluble ActRII polypeptide,” as usedherein, includes any naturally occurring extracellular domain of anActRII protein as well as any variants thereof (including mutants,fragments, and peptidomimetic forms) that retain a useful activity(e.g., a GDF Trap polypeptide as described herein). Other examples ofsoluble ActRII polypeptides comprise a signal sequence in addition tothe extracellular domain of an ActRII or GDF Trap protein. For example,the signal sequence can be a native signal sequence of an ActRIIA orActRIIB protein, or a signal sequence from another protein including,for example, a tissue plasminogen activator (TPA) signal sequence or ahoney bee melittin (HBM) signal sequence.

In part, the present disclosure identifies functionally-active portionsand variants of ActRII polypeptides that can be used as guidance forgenerating and using ActRIIA polypeptides, ActRIIB polypeptides, and GDFTrap polypeptides within the scope of the methods described herein.

ActRII proteins have been characterized in the art in terms ofstructural and functional characteristics, particularly with respect toligand-binding. See, e.g., Attisano et al. (1992) Cell 68(1):97-108;Greenwald et al. (1999) Nature Structural Biology 6(1): 18-22;Allendorph et al. (2006) PNAS 103(20: 7643-7648; Thompson et al. (2003)The EMBO Journal 22(7): 1555-1566; and U.S. Pat. Nos. 7,709,605,7,612,041, and 7,842,663.

For example, Attisano et al. showed that a deletion of the proline knotat the C-terminus of the extracellular domain of ActRIIB reduced theaffinity of the receptor for activin. An ActRIIB-Fc fusion proteincontaining amino acids 20-119 of present SEQ ID NO: 1,“ActRIIB(20-119)-Fc”, has reduced binding to GDF-11 and activin relativeto an ActRIIB(20-134)-Fc, which includes the proline knot region and thecomplete juxtamembrane domain. See, e.g., U.S. Pat. No. 7,842,663.However, an ActRIIB(20-129)-Fc protein retains similar but somewhatreduced activity relative to the wild-type, even though the proline knotregion is disrupted. Thus, ActRIIB extracellular domains that stop atamino acid 134, 133, 132, 131, 130 and 129 (with respect to present SEQID NO:1) are all expected to be active, but constructs stopping at 134or 133 may be most active. Similarly, mutations at any of residues129-134 (with respect to SEQ ID NO: 1) are not expected to alterligand-binding affinity by large margins. In support of this, mutationsof P129 and P130 (with respect to SEQ ID NO:1) do not substantiallydecrease ligand binding. Therefore, an ActRIIB polypeptide or anActRIIB-based GDF Trap polypeptide of the present disclosure may end asearly as amino acid 109 (the final cysteine), however, forms ending ator between 109 and 119 (e.g., 109, 110, 111, 112, 113, 114, 115, 116,117, 118, or 119) are expected to have reduced ligand binding. Aminoacid 119 (with respect to present SEQ ID NO: 1) is poorly conserved andso is readily altered or truncated. ActRIIB polypeptides andActRIIB-based GDF Traps ending at 128 (with respect to present SEQ IDNO:1) or later should retain ligand binding activity. ActRIIBpolypeptides and ActRIIB-based GDF Traps ending at or between 119 and127 (e.g., 119, 120, 121, 122, 123, 124, 125, 126, or 127), with respectto SEQ ID NO: 1, will have an intermediate binding ability. Any of theseforms may be desirable to use, depending on the clinical or experimentalsetting.

At the N-terminus of ActRIIB, it is expected that a protein beginning atamino acid 29 or before (with respect to present SEQ ID NO: 1) willretain ligand-binding activity. Amino acid 29 represents the initialcysteine. An alanine-to-asparagine mutation at position 24 (with respectto present SEQ ID NO: 1) introduces an N-linked glycosylation sequencewithout substantially affecting ligand-binding. See, e.g., U.S. Pat. No.7,842,663. This confirms that mutations in the region between the signalcleavage peptide and the cysteine cross-linked region, corresponding toamino acids 20-29 are well tolerated. In particular, ActRIIBpolypeptides and ActRIIB-based GDF Traps beginning at position 20, 21,22, 23, and 24 (with respect to present SEQ ID NO:1) should retaingeneral ligand-biding activity, and ActRIIB polypeptides andActRIIB-based GDF Traps beginning at positions 25, 26, 27, 28, and 29(with respect to present SEQ ID NO: 1) are also expected to retainligand-biding activity. Data shown herein as well as in, e.g., U.S. Pat.No. 7,842,663 demonstrates that, surprisingly, an ActRIIB constructbeginning at 22, 23, 24, or 25 will have the most activity.

Taken together, an active portion (e.g., ligand-binding activity) ofActRIIB comprises amino acids 29-109 of SEQ ID NO:1. Therefore ActRIIBpolypeptides and ActRIIB-based GDF Traps of the present disclosure may,for example, comprise an amino acid sequence that is at least 80%, 81%,82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%,96%, 97%, 98%, 99%, or 100% identical to a portion of ActRIIB beginningat a residue corresponding to amino acids 20-29 (e.g., beginning atamino acid 20, 21, 22, 23, 24, 25, 26, 27, 28, or 29) of SEQ ID NO: 1and ending at a position corresponding to amino acids 109-134 (e.g.,ending at amino acid 109, 110, 111, 112, 113, 114, 115, 116, 117, 118,119, 120, 121, 122, 123, 124, 125, 126, 127, 128, 129, 130, 131, 132,133, or 134) of SEQ ID NO: 1. In some embodiments, ActRIIB-based GDFTrap polypeptides of the present disclosure do not comprise or consistof amino acids 29-109 of SEQ ID NO: 1. Other examples includepolypeptides that begin at a position from 20-29 (e.g., position 20, 21,22, 23, 24, 25, 26, 27, 28, or 29) or 21-29 (e.g., position 21, 22, 23,24, 25, 26, 27, 28, or 29) and end at a position from 119-134 (e.g.,119, 120, 121, 122, 123, 124, 125, 126, 127, 128, 129, 130, 131, 132,133, or 134), 119-133 (e.g., 119, 120, 121, 122, 123, 124, 125, 126,127, 128, 129, 130, 131, 132, or 133), 129-134 (e.g., 129, 130, 131,132, 133, or 134), or 129-133 (e.g., 129, 130, 131, 132, or 133) of SEQID NO: 1. Other examples include constructs that begin at a positionfrom 20-24 (e.g., 20, 21, 22, 23, or 24), 21-24 (e.g., 21, 22, 23, or24), or 22-25 (e.g., 22, 22, 23, or 25) and end at a position from109-134 (e.g., 109, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119,120, 121, 122, 123, 124, 125, 126, 127, 128, 129, 130, 131, 132, 133, or134), 119-134 (e.g., 119, 120, 121, 122, 123, 124, 125, 126, 127, 128,129, 130, 131, 132, 133, or 134) or 129-134 (e.g., 129, 130, 131, 132,133, or 134) of SEQ ID NO: 1. Variants within these ranges are alsocontemplated, particularly those having at least 80%, 81%, 82%, 83%,84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%,98%, 99%, or 100% identity to the corresponding portion of SEQ ID NO: 1.In some embodiments, the ActRIIB polypeptides and ActRIIB-based GDFTraps comprise a polypeptide having an amino acid sequence that is atleast 80%, 81%, 82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%,93%, 94%, 95%, 96%, 97%, 98%, 99%, or 100% identical to amino acidresidues 25-131 of SEQ ID NO: 1. In certain embodiments, ActRIIB-basedGDF Trap polypeptides do not comprise or consist of amino acids 25-131of SEQ ID NO: 1.

The disclosure includes the results of an analysis of composite ActRIIBstructures, shown in FIG. 1, demonstrating that the ligand-bindingpocket is defined, in part, by residues Y31, N33, N35, L38 through T41,E47, E50, Q53 through K55, L57, H58, Y60, S62, K74, W78 through N83,Y85, R87, A92, and E94 through F101. At these positions, it is expectedthat conservative mutations will be tolerated, although a K74A mutationis well-tolerated, as are R40A, K55A, F82A and mutations at positionL79. R40 is a K in Xenopus, indicating that basic amino acids at thisposition will be tolerated. Q53 is R in bovine ActRIIB and K in XenopusActRIIB, and therefore amino acids including R, K, Q, N and H will betolerated at this position. Thus, a general formula for an ActRIIBpolypeptide and ActRIIB-based GDF Trap polypeptide of the disclosure isone that comprises an amino acid sequence that is at least 80%, 81%,82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%,96%, 97%, 98%, 99%, or 100% identical to amino acids 29-109 of SEQ IDNO: 1, optionally beginning at a position ranging from 20-24 (e.g., 20,21, 22, 23, or 24) or 22-25(e.g., 22, 23, 24, or 25) and ending at aposition ranging from 129-134 (e.g., 129, 130, 131, 132, 133, or 134),and comprising no more than 1, 2, 5, 10 or 15 conservative amino acidchanges in the ligand-binding pocket, and zero, one or morenon-conservative alterations at positions 40, 53, 55, 74, 79 and/or 82in the ligand-binding pocket. Sites outside the binding pocket, at whichvariability may be particularly well tolerated, include the amino andcarboxy termini of the extracellular domain (as noted above), andpositions 42-46 and 65-73 (with respect to SEQ ID NO:1). An asparagineto alanine alteration at position 65 (N65A) actually improvesligand-binding in the A64 background, and is thus expected to have nodetrimental effect on ligand-binding in the R64 background. See, e.g.,U.S. Pat. No. 7,842,663. This change probably eliminates glycosylationat N65 in the A64 background, thus demonstrating that a significantchange in this region is likely to be tolerated. While an R64A change ispoorly tolerated, R64K is well-tolerated, and thus another basicresidue, such as H may be tolerated at position 64. See, e.g., U.S. Pat.No. 7,842,663.

ActRIIB is well-conserved across nearly all vertebrates, with largestretches of the extracellular domain conserved completely. Many of theligands that bind to ActRIIB are also highly conserved. Accordingly,comparisons of ActRIIB sequences from various vertebrate organismsprovide insights into residues that may be altered. Therefore, anactive, human ActRIIB variant polypeptide and ActRIIB-based GDF Trapuseful in accordance with the presently disclosed methods may includeone or more amino acids at corresponding positions from the sequence ofanother vertebrate ActRIIB, or may include a residue that is similar tothat in the human or other vertebrate sequence. The following examplesillustrate this approach to defining an active ActRIIB variant. L46 is avaline in Xenopus ActRIIB, and so this position may be altered, andoptionally may be altered to another hydrophobic residue, such as V, Ior F, or a non-polar residue such as A. E52 is a K in Xenopus,indicating that this site may be tolerant of a wide variety of changes,including polar residues, such as E, D, K, R, H, S, T, P, G, Y andprobably A. T93 is a K in Xenopus, indicating that a wide structuralvariation is tolerated at this position, with polar residues favored,such as S, K, R, E, D, H, G, P, G and Y. F108 is a Y in Xenopus, andtherefore Y or other hydrophobic group, such as I, V or L should betolerated. E111 is K in Xenopus, indicating that charged residues willbe tolerated at this position, including D, R, K and H, as well as Q andN. R112 is K in Xenopus, indicating that basic residues are tolerated atthis position, including R and H. A at position 119 is relatively poorlyconserved, and appears as P in rodents and V in Xenopus, thusessentially any amino acid should be tolerated at this position.

It has been previously demonstrated that the addition of a furtherN-linked glycosylation site (N-X-S/T) is well-tolerated relative to theActRIIB(R64)-Fc form. See, e.g., U.S. Pat. No. 7,842,663. Therefore.N-X-S/T sequences may be generally introduced at positions outside theligand binding pocket defined in FIG. 1 in ActRIIB polypeptide andActRIIB-based GDF Traps of the present disclosure. Particularly suitablesites for the introduction of non-endogenous N-X-S/T sequences includeamino acids 20-29, 20-24, 22-25, 109-134, 120-134 or 129-134 (withrespect to SEQ ID NO: 1). N-X-S/T sequences may also be introduced intothe linker between the ActRIIB sequence and an Fc domain or other fusioncomponent. Such a site may be introduced with minimal effort byintroducing an N in the correct position with respect to a pre-existingS or T, or by introducing an S or T at a position corresponding to apre-existing N. Thus, desirable alterations that would create anN-linked glycosylation site are: A24N, R64N, S67N (possibly combinedwith an N65A alteration), E105N, R112N, G120N, E123N, P129N, A132N,R112S and R112T (with respect to SEQ ID NO:1). Any S that is predictedto be glycosylated may be altered to a T without creating an immunogenicsite, because of the protection afforded by the glycosylation. Likewise,any T that is predicted to be glycosylated may be altered to an S. Thusthe alterations S67T and S44T (with respect to SEQ ID NO: 1) arecontemplated. Likewise, in an A24N variant, an S26T alteration may beused. Accordingly, an ActRIIB polypeptide and ActRIIB-based GDF Trappolypeptide of the present disclosure may be a variant having one ormore additional, non-endogenous N-linked glycosylation consensussequences as described above.

The variations described herein may be combined in various ways.Additionally, the results of the mutagenesis program described hereinindicate that there are amino acid positions in ActRIIB that are oftenbeneficial to conserve. With respect to SEQ ID NO: 1, these includeposition 64 (basic amino acid), position 80 (acidic or hydrophobic aminoacid), position 78 (hydrophobic, and particularly tryptophan), position37 (acidic, and particularly aspartic or glutamic acid), position 56(basic amino acid), position 60 (hydrophobic amino acid, particularlyphenylalanine or tyrosine). Thus, in the ActRIIB polypeptides andActRIIB-based GDF Traps disclosed herein, the disclosure provides aframework of amino acids that may be conserved. Other positions that maybe desirable to conserve are as follows: position 52 (acidic aminoacid), position 55 (basic amino acid), position 81 (acidic), 98 (polaror charged, particularly E, D, R or K), all with respect to SEQ ID NO:1.

A general formula for an active (e.g., ligand binding) ActRIIApolypeptide is one that comprises a polypeptide that starts at aminoacid 30 and ends at amino acid 110 of SEQ ID NO:9. Accordingly, ActRIIApolypeptides and ActRIIA-based GDF Traps of the present disclosure maycomprise a polypeptide that is at least 80%, 81%, 82%, 83%, 84%, 85%,86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99%, or100% identical to amino acids 30-110 of SEQ ID NO:9. In someembodiments, ActRIIA-based GDF Traps of the present disclosure do notcomprise or consist of amino acids 30-110 of SEQ ID NO:9. Optionally,ActRIIA polypeptides and ActRIIA-based GDF Trap polypeptides of thepresent disclosure comprise a polypeptide that is at least 80%, 81%,82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%,96%, 97%, 98%, 99%, or 100% identical to amino acids amino acids 12-82of SEQ ID NO:9 optionally beginning at a position ranging from 1-5(e.g., 1, 2, 3, 4, or 5) or 3-5 (e.g., 3, 4, or 5) and ending at aposition ranging from 110-116 (e.g., 110, 111, 112, 113, 114, 115, or116) or 110-115 (e.g., 110, 111, 112, 113, 114, or 115), respectively,and comprising no more than 1, 2, 5, 10 or 15 conservative amino acidchanges in the ligand binding pocket, and zero, one or morenon-conservative alterations at positions 40, 53, 55, 74, 79 and/or 82in the ligand-binding pocket with respect to SEQ ID NO:9.

In certain embodiments, functionally active fragments of ActRIIpolypeptides (e.g. ActRIIA and ActRIIB polypeptides) and GDF Trappolypeptides of the present disclosure can be obtained by screeningpolypeptides recombinantly produced from the corresponding fragment ofthe nucleic acid encoding an ActRII polypeptide or GDF Trap polypeptide(e.g., SEQ ID NOs: 7, 8, 12, 13, 27, 32, 39, 40, 42, 46, and 48). Inaddition, fragments can be chemically synthesized using techniques knownin the art such as conventional Merrifield solid phase f-Moc or t-Bocchemistry. The fragments can be produced (recombinantly or by chemicalsynthesis) and tested to identify those peptidyl fragments that canfunction as antagonists (inhibitors) of ActRII receptors and/or one ormore ActRII ligands (e.g., GDF11, GDF8, activin A, activin B, activinAB, activin C, activin E, BMP6, BMP7, and/or Nodal).

In some embodiments, an ActRIIA polypeptide of the present disclosure isa polypeptide comprising an amino acid sequence that is at least 75%identical to an amino acid sequence selected from SEQ ID NOs: 9, 10, 11,22, 26, and 28. In certain embodiments, the ActRIIA polypeptidecomprises an amino acid sequence that is at least 80%, 81%, 82%, 83%,84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%.98%, 99%, or 100% identical to an amino acid sequence selected from SEQID NOs: 9, 10, 11, 22, 26, and 28. In certain embodiments, the ActRIIApolypeptide consists essentially of, or consists of, an amino acidsequence that is at least 80%, 81%, 82%, 83%. 84%, 85%, 86%, 87%, 88%,89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99%, or 100% identicalto an amino acid sequence selected from SEQ ID NOs: 9, 10, 11, 22, 26,and 28.

In some embodiments, an ActRIIB polypeptide of the present disclosure isa polypeptide comprising an amino acid sequence that is at least 75%identical to an amino acid sequence selected from SEQ ID NOs: 1, 2, 3,4, 5, 6, 29, 31, and 49. In certain embodiments, the ActRIIB polypeptidecomprises an amino acid sequence that is at least 80%, 81%, 82%, 83%,84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%,98%, 99%, or 100% identical to an amino acid sequence selected from SEQID NOs: 1, 2, 3, 4, 5, 6, 29, 31, and 49. In certain embodiments, theActRIIB polypeptide consists essentially of, or consists of, an aminoacid sequence that is at least 80%, 81%, 82%, 83%, 84%, 85%, 86%, 87%,88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99%, or 100%identical to an amino acid sequence selected from SEQ ID NOs: 1, 2, 3,4, 5, 6, 29, 31, and 49.

In some embodiments, a GDF Trap polypeptide of the present disclosure isa variant ActRIIB polypeptide comprising an amino acid sequence that isat least 75% identical to an amino acid sequence selected from SEQ IDNOs: 1, 2, 3, 4, 5, 6, 29, 30, 31, 36, 37, 38, 41, 44, 45, 49, 50, and51. In certain embodiments, the GDF Trap comprises an amino acidsequence that is at least 80%, 81%, 82%, 83%, 84%, 85%, 86%, 87%, 88%,89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99%, or 100% identicalto an amino acid sequence selected from SEQ ID NOs: 1, 2, 3, 4, 5, 6,29, 30, 31, 36, 37, 38, 41, 44, 45, 49, 50, and 51. In certainembodiments, the GDF Trap comprises an amino acid sequence that is atleast 80%, 81%, 82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%,93%, 94%, 95%, 96%, 97%, 98%, 99%, or 100% identical to an amino acidsequence selected from SEQ ID NOs: 1, 2, 3, 4, 5, 6, 29, 30, 31, 36, 37,38, 41, 44, 45, 49, 50, and 51, wherein the position corresponding toL79 of SEQ ID NO: 1, 4, or 49 is an acidic amino acids (a D or E aminoacid residue). In certain embodiments, the GDF Trap consists essentiallyof, or consists of, an amino acid sequence that at least 80%, 81%, 82%,83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%,97%, 98%, 99%, or 100% identical to an amino acid sequence selected fromSEQ ID NOs: 36, 37, 38, 41, 44, 45, 50, and 51. In certain embodiments,the GDF Trap does not comprise or consists of an amino acid sequenceselected from SEQ ID NOs: 1, 2, 3, 4, 5, 6, 29, and 31.

In some embodiments, a GDF Trap polypeptide of the present disclosure isa variant ActRIIA polypeptide comprising an amino acid sequence that isat least 75% identical to an amino acid sequence selected from SEQ IDNOs: 9, 10, 11, 22, 26, 28, 29, and 31. In certain embodiments, the GDFTrap comprises an amino acid sequence that is at least 80%, 81%, 82%,83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%,97%, 98%, 99%, or 100% identical to an amino acid sequence selected fromSEQ ID NOs: 9, 10, 11, 22, 26, 28, 29, and 31. In certain embodiments,the GDF Trap consists essentially of, or consists of, an amino acidsequence that at least 80%, 81%, 82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%,90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99%, or 100% identical toan amino acid sequence selected from SEQ ID NOs: 9, 10, 11, 22, 26, 28,29, and 31. In certain embodiments, the GDF Trap does not comprise orconsists of an amino acid sequence selected from SEQ ID NOs: 9, 10, 11,22, 26, 28, 29, and 31.

In some embodiments, the present disclosure contemplates makingfunctional variants by modifying the structure of an ActRII polypeptide(e.g. and ActRIIA or ActRIIB polypeptide) or a GDF Trap for suchpurposes as enhancing therapeutic efficacy, or stability (e.g.,shelf-life and resistance to proteolytic degradation in vivo). Variantscan be produced by amino acid substitution, deletion, addition, orcombinations thereof. For instance, it is reasonable to expect that anisolated replacement of a leucine with an isoleucine or valine, anaspartate with a glutamate, a threonine with a serine, or a similarreplacement of an amino acid with a structurally related amino acid(e.g., conservative mutations) will not have a major effect on thebiological activity of the resulting molecule. Conservative replacementsare those that take place within a family of amino acids that arerelated in their side chains. Whether a change in the amino acidsequence of a polypeptide of the disclosure results in a functionalhomolog can be readily determined by assessing the ability of thevariant polypeptide to produce a response in cells in a fashion similarto the wild-type polypeptide, or to bind to one or more ligands, such asGDF11, activin A, activin B, activin AB, activin C, activin E, GDF8,BMP6, and BMP7, as compared to the unmodified or a wild-typepolypeptide.

In certain embodiments, the present disclosure contemplates specificmutations of ActRII polypeptides and GDF Trap polypeptides of thepresent disclosure so as to alter the glycosylation of the polypeptide.Such mutations may be selected so as to introduce or eliminate one ormore glycosylation sites, such as O-linked or N-linked glycosylationsites. Asparagine-linked glycosylation recognition sites generallycomprise a tripeptide sequence, asparagine-X-threonine orasparagine-X-serine (where “X” is any amino acid) which is specificallyrecognized by appropriate cellular glycosylation enzymes. The alterationmay also be made by the addition of, or substitution by, one or moreserine or threonine residues to the sequence of the polypeptide (forO-linked glycosylation sites). A variety of amino acid substitutions ordeletions at one or both of the first or third amino acid positions of aglycosylation recognition site (and/or amino acid deletion at the secondposition) results in non-glycosylation at the modified tripeptidesequence. Another means of increasing the number of carbohydratemoieties on a polypeptide is by chemical or enzymatic coupling ofglycosides to the polypeptide. Depending on the coupling mode used, thesugar(s) may be attached to (a) arginine and histidine; (b) freecarboxyl groups; (c) free sulfhydryl groups such as those of cysteine;(d) free hydroxyl groups such as those of serine, threonine, orhydroxyproline; (e) aromatic residues such as those of phenylalanine,tyrosine, or tryptophan; or (f) the amide group of glutamine. Removal ofone or more carbohydrate moieties present on a polypeptide may beaccomplished chemically and/or enzymatically. Chemical deglycosylationmay involve, for example, exposure of a polypeptide to the compoundtrifluoromethanesulfonic acid, or an equivalent compound. This treatmentresults in the cleavage of most or all sugars except the linking sugar(N-acetylglucosamine or N-acetylgalactosamine), while leaving the aminoacid sequence intact. Enzymatic cleavage of carbohydrate moieties onpolypeptides can be achieved by the use of a variety of endo- andexo-glycosidases as described by Thotakura et al. [Meth. Enzymol. (1987)138:350]. The sequence of a polypeptide may be adjusted, as appropriate,depending on the type of expression system used, as mammalian, yeast,insect, and plant cells may all introduce differing glycosylationpatterns that can be affected by the amino acid sequence of the peptide.In general, ActRII polypeptides and GDF Trap polypeptides of the presentdisclosure for use in humans may be expressed in a mammalian cell linethat provides proper glycosylation, such as HEK293 or CHO cell lines,although other mammalian expression cell lines are expected to be usefulas well.

This disclosure further contemplates a method of generating mutants,particularly sets of combinatorial mutants of ActRII polypeptides andGDF Trap polypeptides of the present disclosure, as well as truncationmutants. Pools of combinatorial mutants are especially useful foridentifying ActRII and GDF Trap sequences. The purpose of screening suchcombinatorial libraries may be to generate, for example, polypeptidesvariants which have altered properties, such as altered pharmacokineticor altered ligand binding. A variety of screening assays are providedbelow, and such assays may be used to evaluate variants. For example,ActRII polypeptides and GDF Trap polypeptides may be screened forability to bind to an ActRII receptor, to prevent binding of an ActRIIligand (e.g., GDF11, GDF8, activin A, activin B, activin AB, activin C,activin E, BMP7, BMP6, and/or Nodal) to an ActRII polypeptide, or tointerfere with signaling caused by an ActRII ligand.

The activity of an ActRII polypeptides or GDF Trap polypeptides may alsobe tested in a cell-based or in vivo assay. For example, the effect ofan ActRII polypeptide or GDF Trap polypeptide on the expression of genesinvolved in hematopoiesis may be assessed. This may, as needed, beperformed in the presence of one or more recombinant ActRII ligandproteins (e.g., GDF11, GDF8, activin A, activin B, activin AB, activinC, activin E, BMP7, BMP6, and/or Nodal), and cells may be transfected soas to produce an ActRII polypeptide or GDF Trap polypeptide, andoptionally, an ActRII ligand. Likewise, an ActRII polypeptide or GDFTrap polypeptide may be administered to a mouse or other animal, and oneor more blood count measurements (e.g., an RBC count, hemoglobin, orreticulocyte) or cutaneous ulcer parameters may be assessed using artrecognized methods.

Combinatorial-derived variants can be generated which have a selectiveor generally increased potency relative to a reference ActRIIpolypeptide or GDF Trap polypeptide. Such variants, when expressed fromrecombinant DNA constructs, can be used in gene therapy protocols.Likewise, mutagenesis can give rise to variants which have intracellularhalf-lives dramatically different than the corresponding unmodifiedActRII polypeptide or GDF Trap polypeptide. For example, the alteredprotein can be rendered either more stable or less stable to proteolyticdegradation or other cellular processes which result in destruction of,or otherwise inactivation of an unmodified polypeptide. Such variants,and the genes which encode them, can be utilized to alter ActRIIpolypeptide or GDF Trap polypeptide levels by modulating the half-lifeof the polypeptide. For instance, a short half-life can give rise tomore transient biological effects and, when part of an inducibleexpression system, can allow tighter control of recombinant ActRIIpolypeptide or GDF Trap polypeptide levels within the cell. In an Fcfusion protein, mutations may be made in the linker (if any) and/or theFc portion to alter the half-life of the protein.

A combinatorial library may be produced by way of a degenerate libraryof genes encoding a library of polypeptides which each include at leasta portion of potential ActRII or GDF Trap sequences. For instance, amixture of synthetic oligonucleotides can be enzymatically ligated intogene sequences such that the degenerate set of potential ActRII or GDFTrap polypeptide encoding nucleotide sequences are expressible asindividual polypeptides, or alternatively, as a set of larger fusionproteins (e.g., for phage display).

There are many ways by which the library of potential homologs can begenerated from a degenerate oligonucleotide sequence. Chemical synthesisof a degenerate gene sequence can be carried out in an automatic DNAsynthesizer, and the synthetic genes can then be ligated into anappropriate vector for expression. The synthesis of degenerateoligonucleotides is well known in the art. See, e.g., Narang, S A (1983)Tetrahedron 39:3; Itakura et al. (1981) Recombinant DNA, Proc. 3rdCleveland Sympos. Macromolecules, ed. AG Walton, Amsterdam: Elsevier pp273-289; Itakura et al. (1984) Annu. Rev. Biochem. 53:323; Itakura etal. (1984) Science 198:1056; Ike et al. (1983) Nucleic Acid Res. 11:477.Such techniques have been employed in the directed evolution of otherproteins. See, e.g., Scott et al., (1990) Science 249:386-390; Robertset al. (1992) PNAS USA 89:2429-2433; Devlin et al. (1990) Science 249:404-406; Cwirla et al., (1990) PNAS USA 87: 6378-6382; as well as U.S.Pat. Nos. 5,223,409, 5,198,346, and 5,096,815).

Alternatively, other forms of mutagenesis can be utilized to generate acombinatorial library. For example, ActRII polypeptides or GDF Trappolypeptides of the present disclosure can be generated and isolatedfrom a library by screening using, for example, alanine scanningmutagenesis [see, e.g., Ruf et al. (1994) Biochemistry 33:1565-1572;Wang et al. (1994) J. Biol. Chem. 269:3095-3099; Balint et al. (1993)Gene 137:109-118; Grodberg et al. (1993) Eur. J. Biochem. 218:597-601;Nagashima et al. (1993) J. Biol. Chem. 268:2888-2892; Lowman et al.(1991) Biochemistry 30:10832-10838; and Cunningham et al. (1989) Science244:1081-1085], by linker scanning mutagenesis (see, e.g., Gustin et al.(1993) Virology 193:653-660; and Brown et al. (1992) Mol. Cell Biol.12:2644-2652; McKnight et al. (1982) Science 232:316), by saturationmutagenesis [see, e.g., Meyers et al., (1986) Science 232:613]; by PCRmutagenesis [see, e.g., Leung et al. (1989) Method Cell Mol Biol1:11-19]; or by random mutagenesis, including chemical mutagenesis [see,e.g., Miller et al. (1992) A Short Course in Bacterial Genetics, CSHLPress, Cold Spring Harbor, N.Y.; and Greener et al. (1994) Strategies inMol Biol 7:32-34]. Linker scanning mutagenesis, particularly in acombinatorial setting, is an attractive method for identifying truncated(bioactive) forms of ActRII polypeptides.

A wide-range of techniques are known in the art for screening geneproducts of combinatorial libraries made by point mutations andtruncations, and, for that matter, for screening cDNA libraries for geneproducts having a certain property. Such techniques will be generallyadaptable for rapid screening of the gene libraries generated by thecombinatorial mutagenesis of ActRII polypeptides or GDF Trappolypeptides of the disclosure. The most widely used techniques forscreening large gene libraries typically comprises cloning the genelibrary into replicable expression vectors, transforming appropriatecells with the resulting library of vectors, and expressing thecombinatorial genes under conditions in which detection of a desiredactivity facilitates relatively easy isolation of the vector encodingthe gene whose product was detected. In some embodiments, assays includeActRII ligand (e.g., GDF11, GDF8, activin A, activin B, activin AB,activin C, activin E, BMP7, BMP6, and/or Nodal) binding assays and/orActRII ligand-mediated cell signaling assays.

In certain embodiments, ActRII polypeptides or GDF Trap polypeptides ofthe present disclosure may further comprise post-translationalmodifications in addition to any that are naturally present in theActRII (e.g., an ActRIIA or ActRIIB polypeptide) or GDF Trappolypeptide. Such modifications include, but are not limited to,acetylation, carboxylation, glycosylation, phosphorylation, lipidation,and acylation. As a result, the ActRII polypeptide or GDF Trappolypeptide may contain non-amino acid elements, such as polyethyleneglycols, lipids, polysaccharide- or mono-saccharide, and phosphates.Effects of such non-amino acid elements on the functionality of a ligandTrap polypeptide may be tested as described herein for other ActRII orGDF Trap variants. When a polypeptide of the disclosure is produced incells by cleaving a nascent form of the polypeptide, post-translationalprocessing may also be important for correct folding and/or function ofthe protein. Different cells (e.g., CHO, HeLa, MDCK, 293, W138, NIH-3T3or HEK293) have specific cellular machinery and characteristicmechanisms for such post-translational activities and may be chosen toensure the correct modification and processing of the ActRIIpolypeptides or GDF Trap polypeptides.

In certain aspects, ActRII polypeptides or GDF Trap polypeptides of thepresent disclosure include fusion proteins having at least a portion(domain) of an ActRII polypeptide (e.g., an ActRIIA or ActRIIBpolypeptide) or GDF Trap polypeptide and one or more heterologousportions (domains). Well known examples of such fusion domains include,but are not limited to, polyhistidine, Glu-Glu, glutathione Stransferase (GST), thioredoxin, protein A, protein G, an immunoglobulinheavy chain Fc region, maltose binding protein (MBP), or human serumalbumin. A fusion domain may be selected so as to confer a desiredproperty. For example, some fusion domains are particularly useful forisolation of the fusion proteins by affinity chromatography. For thepurpose of affinity purification, relevant matrices for affinitychromatography, such as glutathione-, amylase-, and nickel- orcobalt-conjugated resins are used. Many of such matrices are availablein “kit” form, such as the Pharmacia GST purification system and theQIAexpress™system (Qiagen) useful with (HIS₆) (SEQ ID NO:66)fusionpartners. As another example, a fusion domain may be selected so as tofacilitate detection of the ligand Trap polypeptides. Examples of suchdetection domains include the various fluorescent proteins (e.g., GFP)as well as “epitope tags,” which are usually short peptide sequences forwhich a specific antibody is available. Well known epitope tags forwhich specific monoclonal antibodies are readily available include FLAG,influenza virus haemagglutinin (HA), and c-myc tags. In some cases, thefusion domains have a protease cleavage site, such as for Factor Xa orThrombin, which allows the relevant protease to partially digest thefusion proteins and thereby liberate the recombinant proteins therefrom.The liberated proteins can then be isolated from the fusion domain bysubsequent chromatographic separation. In certain embodiments, an ActRIIpolypeptide or a GDF Trap polypeptide is fused with a domain thatstabilizes the polypeptide in vivo (a “stabilizer” domain). By“stabilizing” is meant anything that increases serum half-life,regardless of whether this is because of decreased destruction,decreased clearance by the kidney, or other pharmacokinetic effect.Fusions with the Fc portion of an immunoglobulin are known to conferdesirable pharmacokinetic properties on a wide range of proteins.Likewise, fusions to human serum albumin can confer desirableproperties. Other types of fusion domains that may be selected includemultimerizing (e.g., dimerizing, tetramerizing) domains and functionaldomains (that confer an additional biological function, such as furtherstimulation of muscle growth).

In certain embodiments, the present disclosure provides ActRII or GDFTrap fusion proteins comprising an immunoglobulin Fc domain. In someembodiments, the immunoglobulin Fc domain is a mammalian immunoglobulindomain. In some embodiments, the immunoglobulin Fc domain is a humanimmunoglobulin domain. In some embodiments, the immunoglobulin Fc domainis a mouse immunoglobulin domain. In certamin embodiments, theimmunoglobulin Fc domain is an IgA, IgD, IgE, IgG, or IgM Fc domain. Incertain embodiments, the immunoglobulin Fc domain is an IgG₁, IgG₂,IgG₃, IgG₄, IgA₁, or IgA₂ Fc domain. In some embodiments, theimmunoglobulin Fe domain is a human IgG1 Fc domain, or a human IgG2 Fcdomain.

In certain embodiments, the present disclosure provides ActRII or GDFTrap fusion proteins comprising the following IgG1 Fc domain sequence:

(SEQ ID NO: 14) 1 THTCPPCPAP ELLGGPSVFL FPPKPKDTLM ISRTPEVTCV VVDVSHEDPE51 VKFNWYVDGV EVHNAKTKPR EEQYNSTYRV VSVLTVLHQD WLNGKEYKCK 101 VSNKALPVPIEKTISKAKGQ PREPQVYTLP PSREEMTKNQ VSLTCLVKGF 151 YPSDIAVEWE SNGQPENNYKTTPPVLDSDG SFFLYSKLTV DKSRWQQGNV 201 FSCSVMHEAL HNHYTQKSLS LSPGK.

In other embodiments, the present disclosure provides ActRII or GDF Trapfusion proteins comprising the following variants of the IgG1 Fe domain:

(SEQ ID NO: 64) 1 THTCPPCPAP ELLGGPSVFL FPPKPKDTLM ISRTPEVTCV VVDVSHEDPE51 VKFNWYVDGV EVHNAKTKPR EEQYNSTYRV VSVLTVLHQD WLNGKEYKCK 101 VSNKALPAPIEKTISKAKGQ PREPQVYTLP PSREEMTKNQ VSLTCLVKGF 151 YPSDIAVEWE SNGQPENNYKTTPPVLDSDG SFFLYSKLTV DKSRWQQGNV 201 FSCSVMHEAL HNHYTQKSLS LSPGK (SEQ IDNO: 15) 1 THTCPPCPAP ELLGGPSVFL FPPKPKDTLM ISRTPEVTCV VVD(A)VSHEDPE 51VKFNWYVDGV EVHNAKTKPR EEQYNSTYRV VSVLTVLHQD WLNGKEYKCK(A) 101 VSNKALPVPIEKTISKAKGQ PREPQVYTLP PSREEMTKNQ VSLTCLVKGF 151 YPSDIAVEWE SNGQPENNYKTTPPVLDSDG PFFLYSKLTV DKSRWQQGNV 201 FSCSVMHEAL HN(A)HYTQKSLS LSPGK.

Optionally, the IgG1 Fc domain has one or more mutations at residuessuch as Asp-265, lysine 322, and Asn-434. In certain cases, the mutantIgG1 Fc domain having one or more of these mutations (e.g., Asp-265mutation) has reduced ability of binding to the Fcγ receptor relative toa wild-type Fe domain. In other cases, the mutant Fc domain having oneor more of these mutations (e.g., Asn-434 mutation) has increasedability of binding to the MHC class I-related Fc-receptor (FcRN)relative to a wild-type IgG1 Fc domain.

In certain other embodiments, the present disclosure provides ActRII orGDF trap fusion proteins comprising variants of the IgG2 Fc domain,including the following:

(SEQ ID NO: 65) 1 VECPPCPAPP VAGPSVFLFP PKPKDTLMIS RTPEVTCVVV DVSHEDPEVQ51 FNWYVDGVEV HNAKTKPREE QFNSTFRVVS VLTVVHQDWL NGKEYKCKVS 101 NKGLPAPIEKTISKTKGQPR EPQVYTLPPS REEMTKNQVS LTCLVKGFYP 151 SDIAVEWESN GQPENNYKTTPPMLDSDGSF FLYSKLTVDK SRWQQGNVFS 201 CSVMHEALHN HYTQKSLSLS PGK

It is understood that different elements of the fusion proteins may bearranged in any manner that is consistent with the desiredfunctionality. For example, an ActRII polypeptide domain or GDF Trappolypeptide domain may be placed C-terminal to a heterologous domain, oralternatively, a heterologous domain may be placed C-terminal to anActRII polypeptide domain or GDF Trap polypeptide domain. The ActRIIpolypeptide domain or GDF Trap polypeptide domain and the heterologousdomain need not be adjacent in a fusion protein, and additional domainsor amino acid sequences may be included C- or N-terminal to eitherdomain or between the domains.

For example, an ActRII or GDF Trap fusion protein may comprises an aminoacid sequence as set forth in the formula A-B-C. The B portioncorresponds to an ActRII polypeptide domain or a GDF Trap polypeptidedomain. The A and C portions may be independently zero, one or more thanone amino acids, and both the A and C portions when present areheterologous to B. The A and/or C portions may be attached to the Bportion via a linker sequence. Exemplary linkers are include shortpolypeptide linkers such as 2-10, 2-5, 2-4, 2-3 glycine residues (SEQ IDNO:67, such as, for example, a Gly-Gly-Gly linker. Other suitablelinkers are described herein above [e.g., a TGGG linker (SEQ ID NO:53)].In certain embodiments, an ActRII or GDF Trap fusion protein comprisesan amino acid sequence as set forth in the formula A-B-C, wherein A is aleader (signal) sequence, B consists of an ActRII or GDF polypeptidedomain, and C is a polypeptide portion that enhances one or more of invivo stability, in vivo half-life, uptake/administration, tissuelocalization or distribution, formation of protein complexes, and/orpurification. In certain embodiments, an ActRII or GDF Trap fusionprotein comprises an amino acid sequence as set forth in the formulaA-B-C, wherein A is a TPA leader sequence, B consists of an ActRII orGDF polypeptide domain, and C is an immunoglobulin Fc domain. In someembodiments, fusion proteins comprise the amino acid sequences set forthin any one of SEQ ID NOs: 22, 26, 29, 31, 36, 38, 41, 44, and 51.

In certain embodiments, ActRII polypeptides or GDF Trap polypeptides ofthe present disclosure contain one or more modifications that arecapable of stabilizing the polypeptides. For example, such modificationsenhance the in vitro half-life of the polypeptides, enhance circulatoryhalf-life of the polypeptides, and/or reduce proteolytic degradation ofthe polypeptides. Such stabilizing modifications include, but are notlimited to, fusion proteins (including, for example, fusion proteinscomprising an ActRII polypeptide domain or a GDF Trap polypeptide domainand a stabilizer domain), modifications of a glycosylation site(including, for example, addition of a glycosylation site to apolypeptide of the disclosure), and modifications of carbohydrate moiety(including, for example, removal of carbohydrate moieties from apolypeptide of the disclosure). As used herein, the term “stabilizerdomain” not only refers to a fusion domain (e.g., an immunoglobulin Fcdomain) as in the case of fusion proteins, but also includesnonproteinaceous modifications such as a carbohydrate moiety, ornonproteinaceous moiety, such as polyethylene glycol.

In some embodiments, ActRII polypeptides and GDF Traps to be used inaccordance with the methods described herein are isolated polypeptides.As used herein, an isolated protein or polypeptide is one which has beenseparated from a component of its natural environment. In someembodiments, a polypeptide of the disclosure is purified to greater than95%, 96%, 97%, 98%, or 99% purity as determined by, for example,electrophoretic (e.g., SDS-PAGE, isoelectric focusing (IEF), capillaryelectrophoresis) or chromatographic (e.g., ion exchange or reverse phaseHPLC). Methods for assessment of antibody purity are well known in theart. See, e.g., Flatman et al., (2007) J. Chromatogr. B 848:79-87.

In certain embodiments, ActRII polypeptides and GDF Traps of thedisclosure can be produced by a variety of art-known techniques. Forexample, polypeptides of the disclosure can be synthesized usingstandard protein chemistry techniques such as those described inBodansky, M. Principles of Peptide Synthesis, Springer Verlag, Berlin(1993) and Grant G. A. (ed.), Synthetic Peptides: A User's Guide, W. H.Freeman and Company, New York (1992). In addition, automated peptidesynthesizers are commercially available (see, e.g., Advanced ChemTechModel 396; Milligen/Biosearch 9600). Alternatively, the polypeptides ofthe disclosure, including fragments or variants thereof, may berecombinantly produced using various expression systems (e.g., E. coli,Chinese Hamster Ovary (CHO) cells, COS cells, baculovirus) as is wellknown in the art. In a further embodiment, the modified or unmodifiedpolypeptides of the disclosure may be produced by digestion ofrecombinantly produced full-length ActRII or GDF Trap polypeptides byusing, for example, a protease, e.g., trypsin, thermolysin,chymotrypsin, pepsin, or paired basic amino acid converting enzyme(PACE). Computer analysis (using a commercially available software,e.g., MacVector, Omega, PCGene, Molecular Simulation, Inc.) can be usedto identify proteolytic cleavage sites. Alternatively, such polypeptidesmay be produced from recombinantly produced full-length ActRII or GDFTrap polypeptides using chemical cleavage (e.g., cyanogen bromide,hydroxylamine, etc.).

Any of the ActRII polypeptides disclosed herein (e.g., ActRIIA orActRIIB polypeptides) can be combined with one or more additional ActRIIantagonist agents of the disclosure to achieve the desired effect (e.g.,treat or prevent an anemia, treat or prevent one or more complicationsof anemia such as cutaneous ulcers, etc.). In some embodiments, thedesired effect is treating one or more complications of anemia such ascutaneous ulcers. In some embodiments, the desired effect is preventingone or more complications of anemia such as cutaneous ulcers. Forexample, an ActRII polypeptide disclosed herein can be used incombination with i) one or more additional ActRII polypeptides disclosedherein, ii) one or more GDF Traps disclosed herein; iii) one or moreActRII antagonist antibodies disclosed herein (e.g., an anti-activin Aantibody, an anti-activin B antibody, an anti-activin C antibody, ananti-activin E antibody, an anti-GDF11 antibody, an anti-GDF8 antibody,an anti-BMP6 antibody, an anti-BMP7 antibody, an anti-ActRIIA antibody,and/or or an anti-ActRIIB antibody); iv) one or more small moleculeActRII antagonists disclosed herein (e.g., a small molecule antagonistof one or more of GDF11, GDF8, activin A, activin B, activin AB, activinC, activin E, BMP6, BMP7, Nodal, ActRIIA, and/or ActRIIB); v) one ormore of the polynucleotide ActRII antagonists disclosed herein (e.g., apolynucleotide antagonist of one or more of GDF11, GDF8, activin A,activin B, activin AB, activin C, activin E, BMP6, BMP7. Nodal, ActRIIA,and/or ActRIIB); vi) one or more follistatin polypeptides disclosedherein; and/or vii) one or more FLRG polypeptides disclosed herein.

Similarly, any of the GDF Traps disclosed herein can be combined withone or more additional ActRII antagonist agents of the disclosure toachieve the desired effect (e.g., treat or prevent an anemia, treat orprevent one or more complications of anemia such as cutaneous ulcers,etc.). In some embodiments, the desired effect is treating one or morecomplications of anemia such as cutaneous ulcers. In some embodiments,the desired effect is preventing one or more complications of anemiasuch as cutaneous ulcers. For example, a GDF Trap disclosed herein canbe used in combination with i) one or more additional GDF Trapsdisclosed herein, ii) one or more ActRII polypeptides disclosed herein(e.g., ActRIIA or ActRIIB polypeptides) disclosed herein; iii) one ormore ActRII antagonist antibodies disclosed herein (e.g., ananti-activin A antibody, an anti-activin B antibody, an anti-activin Cantibody, an anti-activin E antibody, an anti-GDF11 antibody, ananti-GDF8 antibody, an anti-BMP6 antibody, an anti-BMP7 antibody, ananti-ActRIIA antibody, and/or or an anti-ActRIIB antibody); iv) one ormore small molecule ActRII antagonists disclosed herein (e.g., a smallmolecule antagonist of one or more of GDF11, GDF8, activin A, activin B,activin AB, activin C, activin E, BMP6, BMP7, Nodal, ActRIIA, and/orActRIIB); v) one or more of the polynucleotide ActRII antagonistsdisclosed herein (e.g., a polynucleotide antagonist of one or more ofGDF11, GDF8, activin A, activin B, activin AB, activin C, activin E,BMP6, BMP7, Nodal, ActRIIA, and/or ActRIIB); vi) one or more follistatinpolypeptides disclosed herein; and/or vii) one or more FLRG polypeptidesdisclosed herein.

B. Nucleic Acids Encoding ActRII Polypeptides and GDF Traps

In certain embodiments, the present disclosure provides isolated and/orrecombinant nucleic acids encoding the ActRII polypeptides and GDF Trappolypeptides (including fragments, functional variants, and fusionproteins thereof) disclosed herein. For example, SEQ ID NO: 12 encodesthe naturally occurring human ActRIIA precursor polypeptide, while SEQID NO: 13 encodes the processed extracellular domain of ActRIIA. Inaddition, SEQ ID NO:7 encodes a naturally occurring human ActRIIBprecursor polypeptide (the R64 variant described above), while SEQ IDNO:8 encodes the processed extracellular domain of ActRIIB (the R64variant described above). The subject nucleic acids may besingle-stranded or double stranded. Such nucleic acids may be DNA or RNAmolecules. These nucleic acids may be used, for example, in methods formaking ActRII-based ligand Trap polypeptides of the present disclosure.

As used herein, isolated nucleic acid(s) refers to a nucleic acidmolecule that has been separated from a component of its naturalenvironment. An isolated nucleic acid includes a nucleic acid moleculecontained in cells that ordinarily contain the nucleic acid molecule,but the nucleic acid molecule is present extrachromosomally or at achromosomal location that is different from its natural chromosomallocation.

In certain embodiments, nucleic acids encoding ActRII polypeptides andGDF Traps of the present disclosure are understood to include nucleicacids that are variants of any one of SEQ ID NOs: 7, 8, 12, 13, 27, 32,39, 40, 42, 43, 46, 47, and 48. Variant nucleotide sequences includesequences that differ by one or more nucleotide substitutions,additions, or deletions including allelic variants, and therefore, willincluding coding sequences that differ from the nucleotide sequencedesignated in any one of SEQ ID NOs: 7, 8, 12, 13, 27, 32, 39, 40, 42,43, 46, 47, and 48.

In certain embodiments, ActRII polypeptides and GDF Traps of the presentdisclosure are encoded by isolated or recombinant nucleic acid sequencesthat are at least 80%, 81%, 82%, 83%, 84%, 85%, 86%, 87%. 88%, 89%, 90%,91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99% or 100% identical to SEQ IDNOs: 7, 8, 12, 13, 27, 32, 39, 40, 42, 43, 46, 47, and 48 In someembodiments, GDF Traps of the present disclosure are not encoded bynucleic acid sequences that comprise or consist of any one of nucleotidesequences corresponding to any one of SEQ ID NOs: 7, 8, 12, 13, 27, and32. One of ordinary skill in the art will appreciate that nucleic acidsequences that are at least 80%, 81%, 82%, 83%, 84%. 85%, 86%, 87%, 88%,89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99%, or 100% identicalto the sequences complementary to SEQ ID NOs: 7, 8, 12, 13, 27, 32, 39,42, 47, and 48, and variants thereof, are also within the scope of thepresent disclosure. In further embodiments, the nucleic acid sequencesof the disclosure can be isolated, recombinant, and/or fused with aheterologous nucleotide sequence, or in a DNA library.

In other embodiments, nucleic acids of the present disclosure alsoinclude nucleotide sequences that hybridize under highly stringentconditions to the nucleotide sequence designated in SEQ ID NOs: 7, 8,12, 13, 27, 32, 39, 40, 42, 43, 46, 47, and 48, complement sequence ofSEQ ID NOs: 7, 8, 12, 13, 27, 32, 39, 40, 42, 43, 46, 47, and 48, orfragments thereof. As discussed above, one of ordinary skill in the artwill understand readily that appropriate stringency conditions whichpromote DNA hybridization can be varied. One of ordinary skill in theart will understand readily that appropriate stringency conditions whichpromote DNA hybridization can be varied. For example, one could performthe hybridization at 6.0× sodium chloride/sodium citrate (SSC) at about45° C., followed by a wash of 2.0×SSC at 50° C. For example, the saltconcentration in the wash step can be selected from a low stringency ofabout 2.0×SSC at 50° C. to a high stringency of about 0.2×SSC at 50° C.In addition, the temperature in the wash step can be increased from lowstringency conditions at room temperature, about 22° C., to highstringency conditions at about 65° C. Both temperature and salt may bevaried, or temperature or salt concentration may be held constant whilethe other variable is changed. In one embodiment, the disclosureprovides nucleic acids which hybridize under low stringency conditionsof 6×SSC at room temperature followed by a wash at 2×SSC at roomtemperature.

Isolated nucleic acids which differ from the nucleic acids as set forthin SEQ ID NOs: 7, 8, 12, 13, 27, 32, 39, 40, 42, 43, 46, 47, and 48 dueto degeneracy in the genetic code are also within the scope of thedisclosure. For example, a number of amino acids are designated by morethan one triplet. Codons that specify the same amino acid, or synonyms(for example, CAU and CAC are synonyms for histidine) may result in“silent” mutations which do not affect the amino acid sequence of theprotein. However, it is expected that DNA sequence polymorphisms that dolead to changes in the amino acid sequences of the subject proteins willexist among mammalian cells. One skilled in the art will appreciate thatthese variations in one or more nucleotides (up to about 3-5% of thenucleotides) of the nucleic acids encoding a particular protein mayexist among individuals of a given species due to natural allelicvariation. Any and all such nucleotide variations and resulting aminoacid polymorphisms are within the scope of this disclosure.

In certain embodiments, the recombinant nucleic acids of the presentdisclosure may be operably linked to one or more regulatory nucleotidesequences in an expression construct. Regulatory nucleotide sequenceswill generally be appropriate to the host cell used for expression.Numerous types of appropriate expression vectors and suitable regulatorysequences are known in the art for a variety of host cells. Typically,said one or more regulatory nucleotide sequences may include, but arenot limited to, promoter sequences, leader or signal sequences,ribosomal binding sites, transcriptional start and terminationsequences, translational start and termination sequences, and enhanceror activator sequences. Constitutive or inducible promoters as known inthe art are contemplated by the disclosure. The promoters may be eithernaturally occurring promoters, or hybrid promoters that combine elementsof more than one promoter. An expression construct may be present in acell on an episome, such as a plasmid, or the expression construct maybe inserted in a chromosome. In some embodiments, the expression vectorcontains a selectable marker gene to allow the selection of transformedhost cells. Selectable marker genes are well known in the art and willvary with the host cell used.

In certain aspects of the present disclosure, the subject nucleic acidis provided in an expression vector comprising a nucleotide sequenceencoding an ActRII polypeptide or a GDF Trap and operably linked to atleast one regulatory sequence. Regulatory sequences are art-recognizedand are selected to direct expression of the ActRII or GDF Trappolypeptide. Accordingly, the term regulatory sequence includespromoters, enhancers, and other expression control elements. Exemplaryregulatory sequences are described in Goeddel; Gene ExpressionTechnology: Methods in Enzymology, Academic Press, San Diego, Calif.(1990). For instance, any of a wide variety of expression controlsequences that control the expression of a DNA sequence when operativelylinked to it may be used in these vectors to express DNA sequencesencoding an ActRII or GDF Trap polypeptide. Such useful expressioncontrol sequences, include, for example, the early and late promoters ofSV40, tet promoter, adenovirus or cytomegalovirus immediate earlypromoter, RSV promoters, the lac system, the trp system, the TAC or TRCsystem, T7 promoter whose expression is directed by T7 RNA polymerase,the major operator and promoter regions of phage lambda, the controlregions for fd coat protein, the promoter for 3-phosphoglycerate kinaseor other glycolytic enzymes, the promoters of acid phosphatase, e.g.,Pho5, the promoters of the yeast a-mating factors, the polyhedronpromoter of the baculovirus system and other sequences known to controlthe expression of genes of prokaryotic or eukaryotic cells or theirviruses, and various combinations thereof. It should be understood thatthe design of the expression vector may depend on such factors as thechoice of the host cell to be transformed and/or the type of proteindesired to be expressed. Moreover, the vector's copy number, the abilityto control that copy number and the expression of any other proteinencoded by the vector, such as antibiotic markers, should also beconsidered.

A recombinant nucleic acid of the present disclosure can be produced byligating the cloned gene, or a portion thereof, into a vector suitablefor expression in either prokaryotic cells, eukaryotic cells (yeast,avian, insect or mammalian), or both. Expression vehicles for productionof a recombinant ActRII or GDF Trap polypeptide include plasmids andother vectors. For instance, suitable vectors include plasmids of thefollowing types: pBR322-derived plasmids, pEMBL-derived plasmids,pEX-derived plasmids, pBTac-derived plasmids and pUC-derived plasmidsfor expression in prokaryotic cells, such as E. coli.

Some mammalian expression vectors contain both prokaryotic sequences tofacilitate the propagation of the vector in bacteria, and one or moreeukaryotic transcription units that are expressed in eukaryotic cells.The pcDNAI/amp, pcDNAI/neo, pRc/CMV, pSV2gpt, pSV2neo, pSV2-dhfr, pTk2,pRSVneo, pMSG, pSVT7, pko-neo and pHyg derived vectors are examples ofmammalian expression vectors suitable for transfection of eukaryoticcells. Some of these vectors are modified with sequences from bacterialplasmids, such as pBR322, to facilitate replication and drug resistanceselection in both prokaryotic and eukaryotic cells. Alternatively,derivatives of viruses such as the bovine papilloma virus (BPV-1), orEpstein-Barr virus (pHEBo, pREP-derived and p205) can be used fortransient expression of proteins in eukaryotic cells. Examples of otherviral (including retroviral) expression systems can be found below inthe description of gene therapy delivery systems. The various methodsemployed in the preparation of the plasmids and in transformation ofhost organisms are well known in the art. For other suitable expressionsystems for both prokaryotic and eukaryotic cells, as well as generalrecombinant procedures. See, e.g., Molecular Cloning A LaboratoryManual, 3rd Ed., ed. by Sambrook, Fritsch and Maniatis (Cold SpringHarbor Laboratory Press, 2001). In some instances, it may be desirableto express the recombinant polypeptides by the use of a baculovirusexpression system. Examples of such baculovirus expression systemsinclude pVL-derived vectors (such as pVL1392, pVL1393 and pVL941),pAcUW-derived vectors (such as pAcUW1), and pBlueBac-derived vectors(such as the β-gal containing pBlueBac III).

In some embodiments, a vector will be designed for production of thesubject ActRII or GDF Trap polypeptides in CHO cells, such as aPcmv-Script vector (Stratagene, La Jolla, Calif.), pcDNA4 vectors(Invitrogen, Carlsbad, Calif.) and pCI-neo vectors (Promega, Madison,Wisc.). As will be apparent, the subject gene constructs can be used tocause expression of the subject ActRII polypeptides in cells propagatedin culture, e.g., to produce proteins, including fusion proteins orvariant proteins, for purification.

This disclosure also pertains to a host cell transfected with arecombinant gene including a coding sequence for one or more of thesubject ActRII or GDF Trap polypeptides. The host cell may be anyprokaryotic or eukaryotic cell. For example, an ActRII or GDF Trappolypeptide of the disclosure may be expressed in bacterial cells suchas E. coli, insect cells (e.g., using a baculovirus expression system),yeast, or mammalian cells [e.g. a Chinese hamster ovary (CHO) cellline]. Other suitable host cells are known to those skilled in the art.

Accordingly, the present disclosure further pertains to methods ofproducing the subject ActRII and GDF Trap polypeptides. For example, ahost cell transfected with an expression vector encoding an ActRII orGDF Trap polypeptide can be cultured under appropriate conditions toallow expression of the ActRII or GDF Trap polypeptide to occur. Thepolypeptide may be secreted and isolated from a mixture of cells andmedium containing the polypeptide. Alternatively, the ActRII or GDF Trappolypeptide may be retained cytoplasmically or in a membrane fractionand the cells harvested, lysed and the protein isolated. A cell cultureincludes host cells, media and other byproducts. Suitable media for cellculture are well known in the art. The subject polypeptides can beisolated from cell culture medium, host cells, or both, using techniquesknown in the art for purifying proteins, including ion-exchangechromatography, gel filtration chromatography, ultrafiltration,electrophoresis, immunoaffinity purification with antibodies specificfor particular epitopes of the ActRII or GDF Trap polypeptides andaffinity purification with an agent that binds to a domain fused to theActRII or GDF Trap polypeptide (e.g., a protein A column may be used topurify an ActRII-Fc or GDF Trap-Fc fusion protein). In some embodiments,the ActRII or GDF Trap polypeptide is a fusion protein containing adomain which facilitates its purification.

In some embodiments, purification is achieved by a series of columnchromatography steps, including, for example, three or more of thefollowing, in any order: protein A chromatography, Q sepharosechromatography, phenylsepharose chromatography, size exclusionchromatography, and cation exchange chromatography. The purificationcould be completed with viral filtration and buffer exchange. AnActRII-Fc or GDF Trap-Fc protein may be purified to a purityof >90%, >95%, >96%, >98%, or >99% as determined by size exclusionchromatography and >90%, >95%, >96%, >98%, or >99% as determined by SDSPAGE. The target level of purity should be one that is sufficient toachieve desirable results in mammalian systems, particularly non-humanprimates, rodents (mice), and humans.

In another embodiment, a fusion gene coding for a purification leadersequence, such as a poly-(His)/enterokinase cleavage site sequence atthe N-terminus of the desired portion of the recombinant ActRII or GDFTrap polypeptide, can allow purification of the expressed fusion proteinby affinity chromatography using a Ni²⁺ metal resin. The purificationleader sequence can then be subsequently removed by treatment withenterokinase to provide the purified ActRII or GDF Trap polypeptide.See, e.g., Hochuli et al. (1987) J. Chromatography 411:177; andJanknecht et al. (1991) PNAS USA 88:8972.

Techniques for making fusion genes are well known. Essentially, thejoining of various DNA fragments coding for different polypeptidesequences is performed in accordance with conventional techniques,employing blunt-ended or stagger-ended termini for ligation, restrictionenzyme digestion to provide for appropriate termini, filling-in ofcohesive ends as appropriate, alkaline phosphatase treatment to avoidundesirable joining, and enzymatic ligation. In another embodiment, thefusion gene can be synthesized by conventional techniques includingautomated DNA synthesizers. Alternatively, PCR amplification of genefragments can be carried out using anchor primers which give rise tocomplementary overhangs between two consecutive gene fragments which cansubsequently be annealed to generate a chimeric gene sequence. See,e.g., Current Protocols in Molecular Biology, eds. Ausubel et al., JohnWiley & Sons: 1992.

C. Antibody Antagonist

In certain aspects, the present disclosure relates to an antibody, orcombination of antibodies, that antagonize ActRII activity (e.g.,inhibition of ActRIIA and/or ActRIIB signaling transduction, such asSMAD 2/3 and/or SMAD 1/5/8 signaling). In particular, the disclosureprovides methods of using an antibody ActRII antagonist, or combinationof antibody ActRII antagonists, to, e.g., treat or prevent an anemia ina subject in need thereof and/or treat or prevent one or morecomplication of anemia including, for example, cutaneous ulcers. In someembodiments, the disclosure provides methods of using an antibody ActRIIantagonist, or combination of antibody ActRII antagonists, to treat ananemia in a subject in need thereof and/or treat one or morecomplications of anemia including, for example, cutaneous ulcers in asubject having anemia. In some embodiments, the disclosure providesmethods of using an antibody ActRII antagonist, or combination ofantibody ActRII antagonists, to prevent an anemia in a subject in needthereof and/or prevent one or more complications of anemia including,for example, cutaneous ulcers in a subject having anemia.

In certain embodiments, an antibody ActRII antagonist of the disclosureis an antibody, or combination of antibodies, that binds to and/orinhibits activity of at least GDF11 (e.g., GDF11-mediated activation ofActRIIA and/or ActRIIB signaling transduction, such as SMAD 2/3signaling). Optionally, the antibody, or combination of antibodies,further binds to and/or inhibits activity of GDF8 (e.g., GDF8-mediatedactivation of ActRIIA and/or ActRIIB signaling transduction, such asSMAD 2/3 signaling), particularly in the case of a multi-specificantibody that has binding affinity for both GDF11 and GDF8 or in thecontext of a combination of one or more anti-GDF11 antibodies and one ormore anti-GDF8 antibodies. Optionally, an antibody, or combination ofantibodies, of the disclosure does not substantially bind to and/orinhibit activity of activin A (e.g., activin A-mediated activation ofActRIIA or ActRIIB signaling transduction, such as SMAD 2/3 signaling).In some embodiments, an antibody, or combination of antibodies, of thedisclosure that binds to and/or inhibits the activity of GDF11 and/orGDF8 further binds to and/or inhibits activity of one of more of activinA, activin B, activin AB, activin C, activin E, BMP6. BMP7, and Nodal(e.g., activation of ActRIIA or ActRIIB SMAD 2/3 and/or SMAD 1/5/8signaling), particularly in the case of a multi-specific antibody thathas binding affinity for multiple ActRII ligands or in the context of acombination of multiple antibodies—each having binding affinity for adifferent ActRII ligand.

In certain aspects, an ActRII antagonist of the present disclosure is anantibody, or combination of antibodies, that binds to and/or inhibitsactivity of at least GDF8 (e.g., GDF8-mediated activation of ActRIIAand/or ActRIIB signaling transduction, such as SMAD 2/3 signaling).Optionally, the antibody, or combination of antibodies, further binds toand/or inhibits activity of GDF11 (e.g., GDF11-mediated activation ofActRIIA and/or ActRIIB signaling transduction, such as SMAD 2/3signaling), particularly in the case of a multi-specific antibody thathas binding affinity for both GDF8 and GDF11 or in the context of acombination of one or more anti-GDF8 antibodies and one or moreanti-GDF11 antibodies. Optionally, an antibody, or combination ofantibodies, of the disclosure does not substantially bind to and/orinhibit activity of activin A (e.g., activin A-mediated activation ofActRIIA or ActRIIB signaling transduction, such as SMAD 2/3 signaling).In some embodiments, an antibody, or combination of antibodies, of thedisclosure that binds to and/or inhibits the activity of GDF8 and/orGDF11 further binds to and/or inhibits activity of one of more ofactivin A, activin B, activin AB, activin C, activin E, BMP6, BMP7, andNodal (e.g., activation of ActRIIA or ActRIIB signaling transduction,such as SMAD 2/3 and/or SMAD 1/5/8 signaling), particularly in the caseof a multi-specific antibody that has binding affinity for multipleActRII ligands or in the context of a combination multipleantibodies—each having binding affinity for a different ActRII ligand.

In another aspect, an ActRII antagonist of the present disclosure is anantibody, or combination of antibodies, that binds to and/or inhibitsactivity of an ActRII receptor (e.g. an ActRIIA or ActRIIB receptor). Insome embodiments, an anti-ActRII receptor antibody (e.g. an anti-ActRIIAor anti-ActRIIB receptor antibody), or combination of antibodies, of thedisclosure binds to an ActRII receptor and prevents binding and/oractivation of the ActRII receptor by at least GDF11 (e.g.,GDF11-mediated activation of ActRIIA and/or ActRIIB signalingtransduction, such as SMAD 2/3 signaling). Optionally, an anti-ActRIIreceptor antibody, or combination of antibodies, of the disclosurefurther prevents binding and/or activation of the ActRII receptor byGDF8. Optionally, an anti-ActRII receptor antibody, or combination ofantibodies, of the disclosure does not substantially inhibit activin Afrom binding to and/or activating an ActRII receptor. In someembodiments, an anti-ActRII receptor antibody, or combination ofantibodies, of the disclosure that binds to an ActRII receptor andprevents binding and/or activation of the ActRII receptor by GDF11and/or GDF8 further prevents binding and/or activation of the ActRIIreceptor by one or more of activin A, activin B, activin AB, activin C,activin E, BMP6, BMP7, and Nodal.

The term antibody is used herein in the broadest sense and encompassesvarious antibody structures, including but not limited to monoclonalantibodies, polyclonal antibodies, multispecific antibodies (e.g.,bispecific antibodies), and antibody fragments so long as they exhibitthe desired antigen-binding activity. An antibody fragment refers to amolecule other than an intact antibody that comprises a portion of anintact antibody that binds the antigen to which the intact antibodybinds. Examples of antibody fragments include but are not limited to Fv,Fab, Fab′, Fab′-SH, F(ab′)₂; diabodies; linear antibodies; single-chainantibody molecules (e.g., scFv); and multispecific antibodies formedfrom antibody fragments. See, e.g., Hudson et al. (2003) Nat. Med.9:129-134; Plückthun, in The Pharmacology of Monoclonal Antibodies, vol.113, Rosenburg and Moore eds., (Springer-Verlag, New York), pp. 269-315(1994); WO 93/16185; and U.S. Pat. Nos. 5,571,894, 5,587,458, and5,869,046. Antibodies disclosed herein may be polyclonal antibodies ormonoclonal antibodies. In certain embodiments, the antibodies of thepresent disclosure comprise a label attached thereto and able to bedetected (e.g., the label can be a radioisotope, fluorescent compound,enzyme, or enzyme co-factor). In some embodiments, the antibodies of thepresent disclosure are isolated antibodies.

Diabodies are antibody fragments with two antigen-binding sites that maybe bivalent or bispecific. See, e.g., EP 404,097; WO 1993/01161; Hudsonet al. (2003) Nat. Med. 9:129-134 (2003); and Hollinger et al. (1993)Proc. Natl. Acad. Sci. USA 90: 6444-6448. Triabodies and tetrabodies arealso described in Hudson et al. (2003) Nat. Med. 9:129-134.

Single-domain antibodies are antibody fragments comprising all or aportion of the heavy chain variable domain or all or a portion of thelight chain variable domain of an antibody. In certain embodiments, asingle-domain antibody is a human single-domain antibody. See, e.g.,U.S. Pat. No. 6,248,516.

Antibody fragments can be made by various techniques, including but notlimited to proteolytic digestion of an intact antibody as well asproduction by recombinant host cells (e.g., E. coli or phage), asdescribed herein.

The antibodies herein may be of any class. The class of an antibodyrefers to the type of constant domain or constant region possessed byits heavy chain. There are five major classes of antibodies: IgA, IgD,IgE, IgG, and IgM, and several of these may be further divided intosubclasses (isotypes), for example, IgG₁, IgG₂, IgG₃, IgG₄, IgA₁, andIgA₂. The heavy chain constant domains that correspond to the differentclasses of immunoglobulins are called alpha, delta, epsilon, gamma, andmu.

In general, an antibody for use in the methods disclosed hereinspecifically binds to its target antigen, preferably with high bindingaffinity. Affinity may be expressed as a K_(D) value and reflects theintrinsic binding affinity (e.g., with minimized avidity effects).Typically, binding affinity is measured in vitro, whether in a cell-freeor cell-associated setting. Any of a number of assays known in the art,including those disclosed herein, can be used to obtain binding affinitymeasurements including, for example, surface plasmon resonance (Biacore™assay), radiolabeled antigen binding assay (RIA), and ELISA. In someembodiments, antibodies of the present disclosure bind to their targetantigens (e.g. GDF11, GDF8, ActRIIA, ActRIIB, etc.) with at least aK_(D) of 1×10⁻⁷ or stronger, 1×10⁻⁸ or stronger, 1×10⁻⁹ or stronger,1×10⁻¹⁰ or stronger, 1×10⁻¹¹ or stronger, 1×10⁻¹² or stronger, 1×10⁻¹³or stronger, or 1×10¹⁴ or stronger.

In certain embodiments, K_(D) is measured by RIA performed with the Fabversion of an antibody of interest and its target antigen as describedby the following assay. Solution binding affinity of Fabs for theantigen is measured by equilibrating Fab with a minimal concentration ofradiolabeled antigen (e.g., ¹²⁵I-labeled) in the presence of a titrationseries of unlabeled antigen, then capturing bound antigen with ananti-Fab antibody-coated plate. See, e.g., Chen et al. (1999) J. Mol.Biol. 293:865-881. To establish conditions for the assay, multi-wellplates (e.g., MICROTITER® from Thermo Scientific) are coated (e.g.,overnight) with a capturing anti-Fab antibody (e.g., from Cappel Labs)and subsequently blocked with bovine serum albumin, preferably at roomtemperature (approximately 23° C.). In a non-adsorbent plate,radiolabeled antigen are mixed with serial dilutions of a Fab ofinterest [e.g., consistent with assessment of the anti-VEGF antibody,Fab-12, in Presta et al., (1997) Cancer Res. 57:4593-4599]. The Fab ofinterest is then incubated, preferably overnight but the incubation maycontinue for a longer period (e.g., about 65 hours) to ensure thatequilibrium is reached. Thereafter, the mixtures are transferred to thecapture plate for incubation, preferably at room temperature for aboutone hour. The solution is then removed and the plate is washed timesseveral times, preferably with polysorbate 20 and PBS mixture. When theplates have dried, scintillant (e.g., MICROSCINT® from Packard) isadded, and the plates are counted on a gamma counter (e.g., TOPCOUNT®from Packard).

According to another embodiment, K_(D) is measured using surface plasmonresonance assays using, for example a BIACORE® 2000 or a BIACORE® 3000(Biacore, Inc., Piscataway, N.J.) with immobilized antigen CM5 chips atabout 10 response units (RU). Briefly, carboxymethylated dextranbiosensor chips (CM5, Biacore Inc.) are activated withN-ethyl-N′-(3-dimethylaminopropyl)-carbodiimide hydrochloride (EDC) andN-hydroxysuccinimide (NHS) according to the supplier's instructions. Forexample, an antigen can be diluted with 10 mM sodium acetate, pH 4.8, to5 μg/ml (about 0.2 μM) before injection at a flow rate of 5 μl/minute toachieve approximately 10 response units (RU) of coupled protein.Following the injection of antigen, 1 M ethanolamine is injected toblock unreacted groups. For kinetics measurements, two-fold serialdilutions of Fab (0.78 nM to 500 nM) are injected in PBS with 0.05%polysorbate 20 (TWEEN-20®) surfactant (PBST) at a flow rate ofapproximately 25 μl/min. Association rates (k_(on)) and dissociationrates (k_(off)) are calculated using, for example, a simple one-to-oneLangmuir binding model (BIACORE® Evaluation Software version 3.2) bysimultaneously fitting the association and dissociation sensorgrams. Theequilibrium dissociation constant (K_(D)) is calculated as the ratiok_(off)/k_(on). See, e.g., Chen et al., (1999) J. Mol. Biol.293:865-881. If the on-rate exceeds, for example, 10⁶ M⁻¹ s⁻¹ by thesurface plasmon resonance assay above, then the on-rate can bedetermined by using a fluorescent quenching technique that measures theincrease or decrease in fluorescence emission intensity (e.g.,excitation=295 nm; emission=340 nm, 16 nm band-pass) of a 20 nManti-antigen antibody (Fab form) in PBS in the presence of increasingconcentrations of antigen as measured in a spectrometer, such as astop-flow equipped spectrophometer (Aviv Instruments) or a 8000-seriesSLM-AMINCO® spectrophotometer (ThermoSpectronic) with a stirred cuvette.

As used herein, anti-GDF11 antibody generally refers to an antibody thatis capable of binding to GDF11 with sufficient affinity such that theantibody is useful as a diagnostic and/or therapeutic agent in targetingGDF11. In certain embodiments, the extent of binding of an anti-GDF11antibody to an unrelated, non-GDF11 protein is less than about 10%, 9%,8%, 7%, 6%, 5%. 4%, 3%, 2%, or less than 1% of the binding of theantibody to GDF11 as measured, for example, by a radioimmunoassay (RIA).In certain embodiments, an anti-GDF11 antibody binds to an epitope ofGDF11 that is conserved among GDF11 from different species. In certainsome embodiments, an anti-GDF11 antibody of the present disclosure is anantagonist antibody that can inhibit GDF11 activity. For example, ananti-GDF11 antibody of the disclosure may inhibit GDF11 from binding toa cognate receptor (e.g., ActRIIA or ActRIIB receptor) and/or inhibitGDF11-mediated signal transduction (activation) of a cognate receptor,such as SMAD2/3 signaling by ActRIIA and/or ActRIIB receptors. In someembodiments, anti-GDF11 antibodies of the present disclosure do notsubstantially bind to and/or inhibit activity of activin A. It should benoted that GDF11 has high sequence homology to GDF8 and thereforeantibodies that bind and/or to GDF11, in some cases, may also bind toand/or inhibit GDF8.

An anti-GDF8 antibody refers to an antibody that is capable of bindingto GDF8 with sufficient affinity such that the antibody is useful as adiagnostic and/or therapeutic agent in targeting GDF8. In certainembodiments, the extent of binding of an anti-GDF8 antibody to anunrelated, non-GDF8 protein is less than about 10%, 9%, 8%, 7%, 6%, 5%,4%, 3%. 2%, or less than 1% of the binding of the antibody to GDF8 asmeasured, for example, by a radioimmunoassay (RIA). In certainembodiments, an anti-GDF8 antibody binds to an epitope of GDF8 that isconserved among GDF8 from different species. In some embodiments, ananti-GDF8 antibody of the present disclosure is an antagonist antibodythat can inhibit GDF8 activity. For example, an anti-GDF8 antibody ofthe disclosure may inhibit GDF8 from binding to a cognate receptor(e.g., ActRIIA or ActRIIB receptor) and/or inhibit GDF8-mediated signaltransduction (activation) of a cognate receptor, such as SMAD2/3signaling by ActRIIA and/or ActRIIB receptors. In some embodiments,anti-GDF8 antibodies of the present disclosure do not substantially bindto and/or inhibit activity of activin A. It should be noted that GDF8has high sequence homology to GDF11 and therefore antibodies that bindand/or to GDF8, in many cases, may also bind to and/or inhibit GDF11.

An anti-ActRIIA antibody refers to an antibody that is capable ofbinding to ActRIIA with sufficient affinity such that the antibody isuseful as a diagnostic and/or therapeutic agent in targeting ActRIIA. Incertain embodiments, the extent of binding of an anti-ActRIIA antibodyto an unrelated, non-ActRIIA protein is less than about 10%, 9%, 8%, 7%,6%, 5%, 4%, 3%, 2%, or less than 1% of the binding of the antibody toActRIIA as measured, for example, by a radioimmunoassay (RIA). Incertain embodiments, an anti-ActRIIA antibody binds to an epitope ofActRIIA that is conserved among ActRIIA from different species. In someembodiments, an anti-ActRIIA antibody of the present disclosure is anantagonist antibody that can inhibit ActRIIA activity. For example, ananti-ActRIIA antibody of the present disclosure may inhibit one or moreActRIIA ligands selected from activin A, activin B, activin AB, activinC, activin E, GDF11, GDF8, activin A, BMP6, and BMP7 from binding to theActRIIA receptor and/or inhibit one of these ligands from activatingActRIIA signaling (e.g., SMAD2/3 and/or SMAD 1/5/8 ActRIIA signaling).In some embodiments, anti-ActRIIA antibodies of the present disclosureinhibit GDF11 from binding to the ActRIIA receptor and/or inhibit GDF11from activating ActRIIA signaling. Optionally, anti-ActRIIA antibodiesof the disclosure further inhibit GDF8 from binding to the ActRIIAreceptor and/or inhibit GDF8 from activating ActRIIA signaling.Optionally, anti-ActRIIA antibodies of the present disclosure do notsubstantially inhibit activin A from binding to the ActRIIA receptorand/or do not substantially inhibit activin A-mediated activation ofActRIIA signaling. In some embodiments, an anti-ActRIIA antibody of thedisclosure that inhibits GDF11 and/or GDF8 from binding to and/oractivating an ActRIIA receptor further inhibits one or more of activinA, activin B, activin AB, activin C, activin E, activin A, GDF8, BMP6,and BMP7 from binding to and/or activating the ActRIIA receptor.

An anti-ActRIIB antibody refers to an antibody that is capable ofbinding to ActRIIB with sufficient affinity such that the antibody isuseful as a diagnostic and/or therapeutic agent in targeting ActRIIB. Incertain embodiments, the extent of binding of an anti-ActRIIB antibodyto an unrelated, non-ActRIIB protein is less than about 10%, 9%, 8%, 7%,6%, 5%, 4%, 3%, 2%, or less than 1% of the binding of the antibody toActRIIB as measured, for example, by a radioimmunoassay (RIA). Incertain embodiments, an anti-ActRIIB antibody binds to an epitope ofActRIIB that is conserved among ActRIIB from different species. In someembodiments, an anti-ActRIIB antibody of the present disclosure is anantagonist antibody that can inhibit ActRIIB activity. For example, ananti-ActRIIB antibody of the present disclosure may inhibit one or moreActRIIB ligands selected from activin A, activin B, activin AB, activinC, activin E, GDF11, GDF8, activin A, BMP6, and BMP7 from binding to theActRIIB receptor and/or inhibit one of these ligands from activatingActRIIB signaling (e.g., SMAD2/3 and/or SMAD 1/5/8 ActRIIB signaling).In some embodiments, anti-ActRIIB antibodies of the present disclosureinhibit GDF11 from binding to the ActRIIB receptor and/or inhibit GDF11from activating ActRIIB signaling. Optionally, anti-ActRIIB antibodiesof the disclosure further inhibit GDF8 from binding to the ActRIIBreceptor and/or inhibit GDF8 from activating ActRIIB signaling.Optionally, anti-ActRIIB antibodies of the present disclosure do notsubstantially inhibit activin A from binding to the ActRIIB receptorand/or do not substantially inhibit activin A-mediated activation ofActRIIB signaling. In some embodiments, an anti-ActRIIB antibody of thedisclosure that inhibits GDF11 and/or GDF8 from binding to and/oractivating an ActRIIB receptor further inhibits one or more of activinA, activin B, activin AB, activin C, activin E, activin A, GDF8, BMP6,and BMP7 from binding to and/or activating the ActRIIB receptor.

The nucleic acid and amino acid sequences of human GDF11. GDF8, activinA, activin B, activin AB, activin C, activin E, GDF8, BMP6, BMP7,ActRIIB, and ActRIIA or are well known in the art and thus antibodyantagonists for use in accordance with this disclosure may be routinelymade by the skilled artisan based on the knowledge in the art andteachings provided herein.

In certain embodiments, an antibody provided herein (e.g., an anti-GDF11antibody, an anti-GDF8 antibody, an anti-ActRIIA antibody, or ananti-ActRIIB antibody) is a chimeric antibody. A chimeric antibodyrefers to an antibody in which a portion of the heavy and/or light chainis derived from a particular source or species, while the remainder ofthe heavy and/or light chain is derived from a different source orspecies. Certain chimeric antibodies are described, for example, in U.S.Pat. No. 4,816,567; and Morrison et al., (1984) Proc. Natl. Acad. Sci.USA, 81:6851-6855. In some embodiments, a chimeric antibody comprises anon-human variable region (e.g., a variable region derived from a mouse,rat, hamster, rabbit, or non-human primate, such as a monkey) and ahuman constant region. In some embodiments, a chimeric antibody is a“class switched” antibody in which the class or subclass has beenchanged from that of the parent antibody. In general, chimericantibodies include antigen-binding fragments thereof.

In certain embodiments, a chimeric antibody provided herein (e.g., ananti-GDF11 antibody, an anti-GDF8 antibody, an anti-ActRIIA antibody, oran anti-ActRIIB antibody) is a humanized antibody. A humanized antibodyrefers to a chimeric antibody comprising amino acid residues fromnon-human hypervariable regions (HVRs) and amino acid residues fromhuman framework regions (FRs). In certain embodiments, a humanizedantibody will comprise substantially all of at least one, and typicallytwo, variable domains, in which all or substantially all of the HVRs(e.g., CDRs) correspond to those of a non-human antibody, and all orsubstantially all of the FRs correspond to those of a human antibody. Ahumanized antibody optionally may comprise at least a portion of anantibody constant region derived from a human antibody. A “humanizedform” of an antibody, e.g., a non-human antibody, refers to an antibodythat has undergone humanization.

Humanized antibodies and methods of making them are reviewed, forexample, in Almagro and Fransson (2008) Front. Biosci. 13:1619-1633 andare further described, for example, in Riechmann et al., (1988) Nature332:323-329; Queen et al. (1989) Proc. Nat'l Acad. Sci. USA86:10029-10033; U.S. Pat. Nos. 5,821,337, 7,527,791, 6,982,321, and7,087,409; Kashmiri et al., (2005) Methods 36:25-34 [describing SDR(a-CDR) grafting]; Padlan, Mol. Immunol. (1991) 28:489-498 (describing“resurfacing”); Dall'Acqua et al. (2005) Methods 36:43-60 (describing“FR shuffling”); Osbourn et al. (2005) Methods 36:61-68; and Klimka etal. Br. J. Cancer (2000) 83:252-260 (describing the “guided selection”approach to FR shuffling).

Human framework regions that may be used for humanization include butare not limited to: framework regions selected using the “best-fit”method [see, e.g., Sims et al. (1993) J. Immunol. 151:2296]; frameworkregions derived from the consensus sequence of human antibodies of aparticular subgroup of light-chain or heavy-chain variable regions [see,e.g., Carter et al. (1992) Proc. Natl. Acad. Sci. USA, 89:4285; andPresta et al. (1993) J. Immunol., 151:2623]; human mature (somaticallymutated) framework regions or human germline framework regions [see,e.g., Almagro and Fransson (2008) Front. Biosci. 13:1619-1633]; andframework regions derived from screening FR libraries (see, e.g., Bacaet ed., (1997) J. Biol. Chem. 272:10678-10684; and Rosok et ed., (1996)J. Biol. Chem. 271:22611-22618).

In certain embodiments, an antibody provided herein (e.g., an anti-GDF11antibody, an anti-GDF8 antibody, an anti-ActRIIA antibody, or ananti-ActRIIB antibody) is a human antibody. Human antibodies can beproduced using various techniques known in the art. Human antibodies aredescribed generally in van Dijk and van de Winkel (2001) Curr. Opin.Pharmacol. 5: 368-74 and Lonberg (2008), Curr. Opin. Immunol.20:450-459.

Human antibodies may be prepared by administering an immunogen (e.g., aGDF11 polypeptide, GDF8 polypeptide, an ActRIIA polypeptide, or anActRIIB polypeptide) to a transgenic animal that has been modified toproduce intact human antibodies or intact antibodies with human variableregions in response to antigenic challenge. Such animals typicallycontain all or a portion of the human immunoglobulin loci, which replacethe endogenous immunoglobulin loci, or which are presentextrachromosomally or integrated randomly into the animal's chromosomes.In such transgenic animals, the endogenous immunoglobulin loci havegenerally been inactivated. For a review of methods for obtaining humanantibodies from transgenic animals see, for example, Lonberg (2005) Nat.Biotechnol. 23:1117-1125; U.S. Pat. Nos. 6,075,181 and 6,150,584(describing XENOMOUSE™ technology); U.S. Pat. No. 5,770,429 (describingHuMab® technology); U.S. Pat. No. 7,041,870 (describing K-M MOUSE®technology); and U.S. Patent Application Publication No. 2007/0061900(describing VelociMouse® technology). Human variable regions from intactantibodies generated by such animals may be further modified, forexample, by combining with a different human constant region.

Human antibodies provided herein can also be made by hybridoma-basedmethods. Human myeloma and mouse-human heteromyeloma cell lines for theproduction of human monoclonal antibodies have been described. See,e.g., Kozbor J. Immunol., (1984) 133: 3001; Brodeur et al. (1987)Monoclonal Antibody Production Techniques and Applications, pp. 51-63,Marcel Dekker, Inc., New York; and Boerner et al. (1991) J. Immunol.,147: 86. Human antibodies generated via human B-cell hybridomatechnology are also described in Li et al., (2006) Proc. Natl. Acad.Sci. USA, 103:3557-3562. Additional methods include those described, forexample, in U.S. Pat. No. 7,189,826 (describing production of monoclonalhuman IgM antibodies from hybridoma cell lines) and Ni, XiandaiMianyixue (2006) 26(4):265-268 (2006) (describing human-humanhybridomas). Human hybridoma technology (Trioma technology) is alsodescribed in Vollmers and Brandlein (2005) Histol. Histopathol.,20(3):927-937 (2005) and Vollmers and Brandlein (2005) Methods Find Exp.Clin. Pharmacol., 27(3): 185-91.

Human antibodies provided herein (e.g., an anti-GDF11 antibody, ananti-activin B antibody, an anti-ActRIIA antibody, or an anti-ActRIIBantibody) may also be generated by isolating Fv clone variable domainsequences selected from human-derived phage display libraries. Suchvariable domain sequences may then be combined with a desired humanconstant domain. Techniques for selecting human antibodies from antibodylibraries are described herein.

For example, antibodies of the present disclosure may be isolated byscreening combinatorial libraries for antibodies with the desiredactivity or activities. A variety of methods are known in the art forgenerating phage display libraries and screening such libraries forantibodies possessing the desired binding characteristics. Such methodsare reviewed, for example, in Hoogenboom et al. (2001) in Methods inMolecular Biology 178:1-37. O'Brien et al., ed., Human Press, Totowa,N.J. and further described, for example, in the McCafferty et al. (1991)Nature 348:552-554; Clackson et al., (1991) Nature 352: 624-628; Markset al. (1992) J. Mol. Biol. 222:581-597; Marks and Bradbury (2003) inMethods in Molecular Biology 248:161-175, Lo, ed., Human Press, Totowa,N.J.; Sidhu et al. (2004) J. Mol. Biol. 338(2):299-310; Lee et al.(2004) J. Mol. Biol. 340(5):1073-1093; Fellouse (2004) Proc. Natl. Acad.Sci. USA 101(34):12467-12472; and Lee et al. (2004) J. Immunol. Methods284(1-2): 119-132.

In certain phage display methods, repertoires of VH and VL genes areseparately cloned by polymerase chain reaction (PCR) and recombinedrandomly in phage libraries, which can then be screened forantigen-binding phage as described in Winter et al. (1994) Ann. Rev.Immunol., 12: 433-455. Phage typically display antibody fragments,either as single-chain Fv (scFv) fragments or as Fab fragments.Libraries from immunized sources provide high-affinity antibodies to theimmunogen (e.g., GDF11, activin B, ActRIIA, or ActRIIB) without therequirement of constructing hybridomas. Alternatively, the naiverepertoire can be cloned (e.g., from human) to provide a single sourceof antibodies directed against a wide range of non-self and alsoself-antigens without any immunization as described by Griffiths et al.(1993) EMBO J, 12: 725-734. Finally, naive libraries can also be madesynthetically by cloning un-rearranged V-gene segments from stem cells,and using PCR primers containing random sequence to encode the highlyvariable CDR3 regions and to accomplish rearrangement in vitro, asdescribed by Hoogenboom and Winter (1992) J. Mol. Biol., 227: 381-388.Patent publications describing human antibody phage libraries include,for example: U.S. Pat. No. 5,750,373, and U.S. Patent Publication Nos.2005/0079574, 2005/0119455, 2005/0266000, 2007/0117126, 2007/0160598,2007/0237764, 2007/0292936, and 2009/0002360.

In certain embodiments, an antibody provided herein is a multi-specificantibody, for example, a bispecific antibody. Multi-specific antibodies(typically monoclonal antibodies) have binding specificities for atleast two different epitopes (e.g., two, three, four, five, or six ormore) on one or more (e.g., two, three, four, five, six or more)antigens.

In certain embodiments, a multi-specific antibody of the presentdisclosure comprises two or more binding specificities, with at leastone of the binding specificities being for a GDF11 epitope, andoptionally one or more additional binding specificities being for anepitope on a different ActRII ligand (e.g., GDF8, activin A, activin B,activin AB, activin C, activin E, BMP6 BMP7 and/or Nodal) and/or anActRII receptor (e.g., an ActRIIA and/or ActRIIB receptor). In certainembodiments, multi-specific antibodies may bind to two or more differentepitopes of GDF11. Preferably a multi-specific antibody of thedisclosure that has binding affinity, in part, for an GDF11 epitope canbe used to inhibit a GDF11 activity (e.g., the ability to bind to and/oractivate an ActRIIA and/or ActRIIB receptor), and optionally inhibit theactivity of one or more different ActRII ligands (e.g., GDF8, activin A,activin B, activin AB, activin C, activin E, BMP6, BMP7 and/or Nodal)and/or an ActRII receptor (e.g., an ActRIIA or ActRIIB receptor). Incertain embodiments, multi-specific antibodies of the present disclosurethat bind to and/or inhibit GDF11 further bind to and/or inhibit atleast GDF8. Optionally, multi-specific antibodies of the disclosure thatbind to and/or inhibit GDF11 do not substantially bind to and/orsubstantially inhibit activin A. In some embodiments, multi-specificantibodies of the disclosure that bind to and/or inhibit GDF11 and GDD8further bind to and/or inhibit one or more of activin A, activin B,activin AB, activin C, activin E, BMP6, BMP7 and/or Nodal.

In certain embodiments, a multi-specific antibody of the presentdisclosure comprises two or more binding specificities, with at leastone of the binding specificities being for a GDF8 epitope, andoptionally one or more additional binding specificities being for anepitope on a different ActRII ligand (e.g., GDF11, activin A, activin B,activin AB, activin C, activin E, BMP6, BMP7 and/or Nodal) and/or anActRII receptor (e.g., an ActRIIA and/or ActRIIB receptor). In certainembodiments, multi-specific antibodies may bind to two or more differentepitopes of GDF8. Preferably a multi-specific antibody of the disclosurethat has binding affinity, in part, for an GDF8 epitope can be used toinhibit an GDF8 activity (e.g., the ability to bind to and/or activatean ActRIIA and/or ActRIIB receptor), and optionally inhibit the activityof one or more different ActRII ligands (e.g., GDF11, activin A, activinB, activin AB, activin C, activin E, BMP6, BMP7 and/or Nodal) and/or anActRII receptor (e.g., an ActRIIA or ActRIIB receptor). In certainembodiments, multi-specific antibodies of the present disclosure thatbind to and/or inhibit GDF8 further bind to and/or inhibit at leastGDF11. Optionally, multi-specific antibodies of the disclosure that bindto and/or inhibit GDF8 do not substantially bind to and/or substantiallyinhibit activin A. In some embodiments, multi-specific antibodies of thedisclosure that bind to and/or inhibit GDF8 and GDF11 further bind toand/or inhibit one or more of activin A, activin B, activin AB, activinC, activin E, BMP6, BMP7 and/or Nodal.

Engineered antibodies with three or more functional antigen bindingsites, including “Octopus antibodies,” are also included herein. See,e.g., US 2006/0025576A1.

In certain embodiments, the antibodies disclosed herein (e.g., ananti-GDF11 antibody, an anti-activin B antibody, an anti-ActRIIAantibody, or an anti-ActRIIB antibody) are monoclonal antibodies.Monoclonal antibody refers to an antibody obtained from a population ofsubstantially homogeneous antibodies, i.e., the individual antibodiescomprising the population are identical and/or bind the same epitope,except for possible variant antibodies, e.g., containing naturallyoccurring mutations or arising during production of a monoclonalantibody preparation, such variants generally being present in minoramounts. In contrast to polyclonal antibody preparations, whichtypically include different antibodies directed against differentepitopes, each monoclonal antibody of a monoclonal antibody preparationis directed against a single epitope on an antigen. Thus, the modifier“monoclonal” indicates the character of the antibody as being obtainedfrom a substantially homogeneous population of antibodies and is not tobe construed as requiring production of the antibody by any particularmethod. For example, the monoclonal antibodies to be used in accordancewith the present methods may be made by a variety of techniques,including but not limited to the hybridoma method, recombinant DNAmethods, phage-display methods, and methods utilizing transgenic animalscontaining all or part of the human immunoglobulin loci, such methodsand other exemplary methods for making monoclonal antibodies beingdescribed herein.

For example, by using immunogens derived from GDF11 or GDF8,anti-protein/anti-peptide antisera or monoclonal antibodies can be madeby standard protocols. See, e.g., Antibodies: A Laboratory Manual (1988)ed. by Harlow and Lane, Cold Spring Harbor Press: 1988. A mammal, suchas a mouse, a hamster, or rabbit can be immunized with an immunogenicform of the GDF11 or GDF8 polypeptide, an antigenic fragment which iscapable of eliciting an antibody response, or a fusion protein.Techniques for conferring immunogenicity on a protein or peptide includeconjugation to carriers or other techniques well known in the art. Animmunogenic portion of a GDF11 or GDF8 polypeptide can be administeredin the presence of adjuvant. The progress of immunization can bemonitored by detection of antibody titers in plasma or serum. StandardELISA or other immunoassays can be used with the immunogen as antigen toassess the levels of antibody production and/or level of bindingaffinity.

Following immunization of an animal with an antigenic preparation ofGDF11 or GDF8, antisera can be obtained and, if desired, polyclonalantibodies can be isolated from the serum. To produce monoclonalantibodies, antibody-producing cells (lymphocytes) can be harvested froman immunized animal and fused by standard somatic cell fusion procedureswith immortalizing cells such as myeloma cells to yield hybridoma cells.Such techniques are well known in the art, and include, for example, thehybridoma technique [see, e.g., Kohler and Milstein (1975) Nature, 256:495-497], the human B cell hybridoma technique [see, e.g., Kozbar et al.(1983) Immunology Today, 4:72], and the EBV-hybridoma technique toproduce human monoclonal antibodies [Cole et al. (1985) MonoclonalAntibodies and Cancer Therapy, Alan R. Liss, Inc. pp. 77-96]. Hybridomacells can be screened immunochemically for production of antibodiesspecifically reactive with a GDF11 or GDF8 polypeptide, and monoclonalantibodies isolated from a culture comprising such hybridoma cells.

In certain embodiments, one or more amino acid modifications may beintroduced into the Fe region of an antibody provided herein (e.g., ananti-GDF11 antibody, an anti-activin B antibody, an anti-ActRIIAantibody, or an anti-ActRIIB antibody), thereby generating an Fc regionvariant. The Fe region variant may comprise a human Fe region sequence(e.g., a human IgG1, IgG2, IgG3 or IgG4 Fc region) comprising an aminoacid modification (e.g., a substitution, deletion, and/or addition) atone or more amino acid positions.

For example, the present disclosure contemplates an antibody variantthat possesses some but not all effector functions, which make it adesirable candidate for applications in which the half-life of theantibody in vivo is important yet for which certain effector functions[e.g., complement-dependent cytotoxicity (CDC) and antibody-dependentcellular cytotoxicity (ADCC)] are unnecessary or deleterious. In vitroand/or in vivo cytotoxicity assays can be conducted to confirm thereduction/depletion of CDC and/or ADCC activities. For example, Fcreceptor (FcR) binding assays can be conducted to ensure that theantibody lacks FcγR binding (hence likely lacking ADCC activity), butretains FcRn binding ability. The primary cells for mediating ADCC, NKcells, express FcγRIII only, whereas monocytes express FcγRI, FcγRII andFcγRIII. FcR expression on hematopoietic cells is summarized in, forexample, Ravetch and Kinet (1991) Annu. Rev. Immunol. 9:457-492.Non-limiting examples of in vitro assays to assess ADCC activity of amolecule of interest are described in U.S. Pat. No. 5,500,362;Hellstrom, I. et al. (1986) Proc. Nat'l Acad. Sci. USA 83:7059-7063];Hellstrom, I et al. (1985) Proc. Nat'l Acad. Sci. USA 82:1499-1502; U.S.Pat. No. 5,821,337; and Bruggemann, M. et al. (1987) J. Exp. Med.166:1351-1361. Alternatively, non-radioactive assays methods may beemployed (e.g., ACTI™, non-radioactive cytotoxicity assay for flowcytometry; CellTechnology, Inc. Mountain View, Calif.; and CytoTox 96®non-radioactive cytotoxicity assay, Promega, Madison, Wis.). Usefuleffector cells for such assays include peripheral blood mononuclearcells (PBMC) and natural killer (NK) cells. Alternatively, oradditionally, ADCC activity of the molecule of interest may be assessedin vivo, for example, in an animal model such as that disclosed inClynes et al. (1998) Proc. Nat'l Acad. Sci. USA 95:652-656. C1q bindingassays may also be carried out to confirm that the antibody is unable tobind C1q and hence lacks CDC activity. See, e.g., C1q and C3c bindingELISA in WO 2006/029879 and WO 2005/100402. To assess complementactivation, a CDC assay may be performed. See, e.g., Gazzano-Santoro etal. (1996) J. Immunol. Methods 202:163; Cragg, M. S. et al. (2003) Blood101:1045-1052; and Cragg, M. S, and M. J. Glennie (2004) Blood103:2738-2743. FcRn binding and in vivo clearance/half-lifedeterminations can also be performed using methods known in the art.See, e.g., Petkova, S. B. et al. (2006) Int'l. Immunol.18(12):1759-1769.

Antibodies of the present disclosure (e.g., an anti-GDF11 antibody, ananti-activin B antibody, an anti-ActRIIA antibody, or an anti-ActRIIBantibody) with reduced effector function include those with substitutionof one or more of Fc region residues 238, 265, 269, 270, 297, 327 and329 (U.S. Pat. No. 6,737,056). Such Fc mutants include Fc mutants withsubstitutions at two or more of amino acid positions 265, 269, 270, 297and 327, including the so-called “DANA” Fc mutant with substitution ofresidues 265 and 297 to alanine (U.S. Pat. No. 7,332,581).

In certain embodiments, it may be desirable to create cysteineengineered antibodies, e.g., “thioMAbs,” in which one or more residuesof an antibody are substituted with cysteine residues. In particularembodiments, the substituted residues occur at accessible sites of theantibody. By substituting those residues with cysteine, reactive thiolgroups are thereby positioned at accessible sites of the antibody andmay be used to conjugate the antibody to other moieties, such as drugmoieties or linker-drug moieties, to create an immunoconjugate, asdescribed further herein. In certain embodiments, any one or more of thefollowing residues may be substituted with cysteine: V205 (Kabatnumbering) of the light chain; A118 (EU numbering) of the heavy chain;and S400 (EU numbering) of the heavy chain Fc region. Cysteineengineered antibodies may be generated as described, for example, inU.S. Pat. No. 7,521,541.

In addition, the techniques used to screen antibodies in order toidentify a desirable antibody may influence the properties of theantibody obtained. For example, if an antibody is to be used for bindingan antigen in solution, it may be desirable to test solution binding. Avariety of different techniques are available for testing interactionbetween antibodies and antigens to identify particularly desirableantibodies. Such techniques include ELISAs, surface plasmon resonancebinding assays (e.g., the Biacore™ binding assay, Bia-core AB, Uppsala,Sweden), sandwich assays (e.g., the paramagnetic bead system of IGENInternational, Inc., Gaithersburg, Md.), western blots,immunoprecipitation assays, and immunohistochemistry.

In certain embodiments, amino acid sequence variants of the antibodiesand/or the binding polypeptides provided herein are contemplated. Forexample, it may be desirable to improve the binding affinity and/orother biological properties of the antibody and/or binding polypeptide.Amino acid sequence variants of an antibody and/or binding polypeptidesmay be prepared by introducing appropriate modifications into thenucleotide sequence encoding the antibody and/or binding polypeptide, orby peptide synthesis. Such modifications include, for example, deletionsfrom, and/or insertions into, and/or substitutions of residues withinthe amino acid sequences of the antibody and/or binding polypeptide. Anycombination of deletion, insertion, and substitution can be made toarrive at the final construct, provided that the final constructpossesses the desired characteristics, e.g., target-binding (GDF11,GDF8, ActRIIA, and/or ActRIIB binding).

Alterations (e.g., substitutions) may be made in HVRs, for example, toimprove antibody affinity. Such alterations may be made in HVR“hotspots,” i.e., residues encoded by codons that undergo mutation athigh frequency during the somatic maturation process (see, e.g.,Chowdhury (2008) Methods Mol. Biol. 207:179-196 (2008)), and/or SDRs(a-CDRs), with the resulting variant VH or VL being tested for bindingaffinity. Affinity maturation by constructing and reselecting fromsecondary libraries has been described in the art. See, e.g., Hoogenboomet al., in Methods in Molecular Biology 178:1-37, O'Brien et al., ed.,Human Press, Totowa, N.J., (2001). In some embodiments of affinitymaturation, diversity is introduced into the variable genes chosen formaturation by any of a variety of methods (e.g., error-prone PCR, chainshuffling, or oligonucleotide-directed mutagenesis). A secondary libraryis then created. The library is then screened to identify any antibodyvariants with the desired affinity. Another method to introducediversity involves HVR-directed approaches, in which several HVRresidues (e.g., 4-6 residues at a time) are randomized. HVR residuesinvolved in antigen binding may be specifically identified, e.g., usingalanine scanning mutagenesis or modeling. CDR-H3 and CDR-L3 inparticular are often targeted.

In certain embodiments, substitutions, insertions, or deletions mayoccur within one or more HVRs so long as such alterations do notsubstantially reduce the ability of the antibody to bind to the antigen.For example, conservative alterations (e.g., conservative substitutionsas provided herein) that do not substantially reduce binding affinitymay be made in HVRs. Such alterations may be outside of HVR “hotspots”or SDRs. In certain embodiments of the variant VH and VL sequencesprovided above, each HVR either is unaltered, or contains no more thanone, two, or three amino acid substitutions.

A useful method for identification of residues or regions of theantibody and/or the binding polypeptide that may be targeted formutagenesis is called “alanine scanning mutagenesis” as described byCunningham and Wells (1989) Science, 244:1081-1085. In this method, aresidue or group of target residues (e.g., charged residues such as Arg,Asp, His, Lys, and Glu) are identified and replaced by a neutral ornegatively charged amino acid (e.g., alanine or polyalanine) todetermine whether the interaction is affected. Further substitutions maybe introduced at the amino acid locations demonstrating functionalsensitivity to the initial substitutions. Alternatively, oradditionally, a crystal structure of an antigen-antibody complex can beused to identify contact points between the antibody and antigen. Suchcontact residues and neighboring residues may be targeted or eliminatedas candidates for substitution. Variants may be screened to determinewhether they contain the desired properties.

Amino acid sequence insertions include amino- and/or carboxyl-terminalfusions ranging in length from one residue to polypeptides containing ahundred or more residues, as well as intrasequence insertions of singleor multiple amino acid residues. Examples of terminal insertions includean antibody with an N-terminal methionyl residue. Other insertionalvariants of the antibody molecule include fusion of the N- or C-terminusof the antibody to an enzyme (e.g., for ADEPT) or a polypeptide whichincreases the serum half-life of the antibody.

In certain embodiments, an antibody and/or binding polypeptide providedherein may be further modified to contain additional non-proteinaceousmoieties that are known in the art and readily available. The moietiessuitable for derivatization of the antibody and/or binding polypeptideinclude but are not limited to water soluble polymers. Non-limitingexamples of water soluble polymers include, but are not limited to,polyethylene glycol (PEG), copolymers of ethylene glycol/propyleneglycol, carboxymethylcellulose, dextran, polyvinyl alcohol, polyvinylpyrrolidone, poly-1,3-dioxolane, poly-1,3,6-trioxane, ethylene/maleicanhydride copolymer, polyaminoacids (either homopolymers or randomcopolymers), and dextran or poly(n-vinyl pyrrolidone)polyethyleneglycol, propropylene glycol homopolymers, prolypropylene oxide/ethyleneoxide co-polymers, polyoxyethylated polyols (e.g., glycerol), polyvinylalcohol, and mixtures thereof. Polyethylene glycol propionaldehyde mayhave advantages in manufacturing due to its stability in water. Thepolymer may be of any molecular weight, and may be branched orunbranched. The number of polymers attached to the antibody and/orbinding polypeptide may vary, and if more than one polymer are attached,they can be the same or different molecules. In general, the numberand/or type of polymers used for derivatization can be determined basedon considerations including, but not limited to, the particularproperties or functions of the antibody and/or binding polypeptide to beimproved, whether the antibody derivative and/or binding polypeptidederivative will be used in a therapy under defined conditions.

Any of the ActRII antagonist antibodies disclosed herein (e.g., ananti-activin A antibody, an anti-activin B antibody, an anti-activin Cantibody, an anti-activin E antibody, an anti-GDF11 antibody, ananti-GDF8 antibody, an anti-BMP6 antibody, an anti-BMP7 antibody, ananti-ActRIIA antibody, and/or or an anti-ActRIIB antibody) can becombined with one or more additional ActRII antagonist agents of thedisclosure to achieve the desired effect (e.g., treat or prevent ananemia in a subject in need thereof and/or treat or prevent one or morecomplications of anemia including, for example, cutaneous ulcers). Forexample, an ActRII antagonist antibody disclosed herein (e.g., ananti-GDF11 antibody, an anti-activin B antibody, an anti-activin Cantibody, an anti-activin E antibody, an anti-GDF11 antibody, ananti-GDF8 antibody, an anti-BMP6 antibody, an-anti-BMP7 antibody, ananti-ActRIIA antibody, or an anti-ActRIIB antibody) can be used incombination with i) one or more additional ActRII antagonist antibodiesdisclosed herein, ii) one or more ActRII polypeptides disclosed herein(e.g., ActRIIA and/or ActRIIB polypeptides), iii) one or more GDF Trapsdisclosed herein; iv) one or more small molecule ActRII antagonistdisclosed herein (e.g., a small molecule antagonist of one or more ofGDF11, GDF8, activin A, activin B, activin AB, activin C, activin E,BMP6, BMP7, Nodal, ActRIIA, and/or ActRIIB); v) one or morepolynucleotide ActRII antagonists disclosed herein (e.g., apolynucleotide antagonist of one or more of GDF11, GDF8, activin A,activin B, activin AB, activin C, activin E, BMP6, BMP7, Nodal, ActRIIA,and/or ActRIIB); vi) one or more follistatin polypeptides disclosedherein; and/or vii) one or more FLRG polypeptides disclosed herein.

D. Small Molecule Antagonists

In another aspect, the present disclosure relates to a small molecule,or combination of small molecules, that antagonizes ActRII activity(e.g., inhibition of ActRIIA and/or ActRIIB signaling transduction, suchas SMAD 2/3 and/or SMAD 1/5/8 signaling). In particular, the disclosureprovides methods of using a small molecule antagonist, or combination ofsmall molecule antagonists, of ActRII to, e.g., treat or prevent ananemia in a subject in need thereof and/or treat or prevent one or morecomplications of anemia including, for example, cutaneous ulcers. Insome embodiments, the disclosure provides methods of using a smallmolecule antagonist, or combination of small molecule antagonists ofActRII, to treat an anemia in a subject in need thereof and/or treat oneor more complications of anemia including, for example, cutaneousulcers, in a subject having anemia. In some embodiments, the disclosureprovides methods of using a small molecule antagonist, or combination ofsmall molecule antagonists of ActRII, to prevent an anemia in a subjectin need thereof and/or prevent one or more complications of anemiaincluding, for example, cutaneous ulcers in a subject having anemia.

In some embodiments, an ActRII antagonist of the present disclosure is asmall molecule antagonist, or combination of small molecule antagonists,that direct or indirect inhibits at least GDF11 activity. Optionally,such a small molecule antagonist, or combination of small moleculeantagonists, may further inhibit, either directly or indirectly, GDF8.Optionally, a small molecule antagonist, or combination of smallmolecule antagonists, of the present disclosure does not substantiallyinhibit activin A activity. In some embodiments, a small moleculeantagonist, or combination of small molecule antagonists, of the presentdisclosure that inhibits, either directly or indirectly, GDF11 and/orGDF8 activity further inhibits, either directly or indirectly, activityof one or more of activin A, activin B, activin AB, activin C, activinE, BMP6, BMP7. Nodal, ActRIIA, and ActRIIB.

In certain embodiments, a small molecule antagonist, or combination ofsmall molecule antagonists, of the present disclosure is an indirectinhibitor of one or more of GDF11, GDF8, activin A, activin B, activinAB, activin C, activin E, BMP6, Nodal, ActRIIA, and ActRIIB. Forexample, a small molecule antagonist, or combination of small moleculeantagonists, of the present disclosure may inhibit the expression (e.g.,transcription, translation, cellular secretion, or combinations thereof)of at least GDF11. Optionally, such a small molecule antagonist, orcombination of small molecule antagonists, may further inhibitexpression of GDF8. Optionally, a small molecule antagonist, orcombinations of small molecule antagonists, of the disclosure does notsubstantially inhibit the expression of activin A. In some embodiments,a small molecule antagonist, or combination of small moleculeantagonists, of the disclosure that inhibits expression of GDF11 and/orGDF8 may further inhibit the expression of one or more of activin A,activin B, activin AB, activin C, activin E, BMP6, BMP7, Nodal, ActRIIA,and ActRIIB.

In other embodiments, a small molecule antagonist, or combination ofsmall molecule antagonists, of the present disclosure is directinhibitor of one or more of GDF11, GDF8, activin A, activin B, activinAB, activin C, activin E, BMP6, BMP7, Nodal, ActRIIA, and ActRIIB. Forexample, a small molecule antagonist, or combination of small moleculeantagonists, of the present disclosure directly binds to and inhibits atleast GDF11 activity (e.g. inhibits the ability GDF11 to bind to anActRIIA and/or ActRIIB receptor; inhibit GDF11-mediated activation ofthe ActRIIA and/or ActRIIB signaling transduction, such as SMAD 2/3signaling). Optionally, a small molecule antagonist, or combinations ofsmall molecule antagonists, of the disclosure may further bind to andinhibit GDF8 activity (e.g. inhibit the ability of GDF8 to bind to anActRIIA and/or ActRIIB receptor; inhibit GDF8-mediated activation of theActRIIA and/or ActRIIB signaling transduction, such as SMAD 2/3signaling). Optionally, a small molecule antagonist, or combinations ofsmall molecule antagonists, of the disclosure does not substantiallybind to or inhibit activin A activity (e.g. the ability of activin A tobind to an ActRIIA and/or ActRIIB receptor; activin A-mediatedactivation of the ActRIIA and/or ActRIIB signaling transduction, such asSMAD 2/3 signaling pathway). In some embodiments, a small moleculeantagonist, or combinations of small molecule antagonists, of thedisclosure that binds to and inhibits the activity of GDF11 and/or GDF8further binds to and inhibits the activity of one or more of activin A,activin B, activin AB, activin C, activin E, BMP6, BMP7, Nodal, ActRIIA,and ActRIIB.

In some embodiments, a small molecule antagonist, or combination ofsmall molecule antagonists, of the present disclosure directly binds toand inhibits at least GDF8 activity (e.g. inhibits the ability GDF8 tobind to an ActRIIA and/or ActRIIB receptor; inhibits GDF8-mediatedactivation of the ActRIIA and/or ActRIIB signaling transduction, such asSMAD 2/3 signaling). Optionally, a small molecule antagonist, orcombinations of small molecule antagonists, of the disclosure mayfurther bind to and inhibit GDF11 activity (e.g. inhibit the ability ofGDF11 to bind to an ActRIIA and/or ActRIIB receptor; inhibitGDF11-mediated activation of the ActRIIA and/or ActRIIB signalingtransduction, such as SMAD 2/3 signaling). Optionally, a small moleculeantagonist, or combinations of small molecule antagonists, of thedisclosure does not substantially bind to or inhibit activin A activity(e.g. the ability of activin A to bind to an ActRIIA and/or ActRIIBreceptor, activin A-mediated activation of the ActRIIA and/or ActRIIBsignaling transduction, SMAD 2/3 signaling). In some embodiments, asmall molecule antagonist, or combinations of small moleculeantagonists, of the disclosure that binds to and inhibits the activityof GDF8 and/or GDF11 further binds to and inhibits the activity of oneor more of activin A, activin B, activin AB, activin C, activin E, BMP6,BMP7, Nodal, ActRIIA, and ActRIIB.

In some embodiments, a small molecule antagonist, or combination ofsmall molecule antagonists, of the present disclosure directly binds toand inhibits at least ActRIIA activity (e.g. ActRII ligand-mediatedactivation of ActRIIA signaling transduction, such as SMAD 2/3signaling). For example, a small molecule antagonist, or combination ofsmall molecule antagonists, of the disclosure binds to an ActRIIAreceptor and inhibits at least GDF11 from binding to and/or activatingthe ActRIIA receptor. Optionally, such a small molecule antagonist, orcombination of small molecule antagonists, may further inhibit GDF8 frombinding to and/or activating the ActRIIA receptor. Optionally, a smallmolecule antagonist, or combination of small molecule antagonists, ofthe disclosure does not substantially inhibit activin A from binding toand/or activating an ActRIIA receptor. In some embodiments, a smallmolecule antagonist, or combination of small molecule antagonists, ofthe disclosure that inhibits GDF11 and/or GDF8 from binding to and/oractivating the ActRIIA receptor further inhibits one or more of activinA, activin B, activin AB, activin C, activin E, BMP6, BMP7. and Nodalfrom binding to/and or activating the ActRIIA receptor.

In some embodiments, a small molecule antagonist, or combination ofsmall molecule antagonists, of the present disclosure directly binds toand inhibits at least ActRIIB activity (e.g.

ActRII ligand-mediated activation of ActRIIB signaling transduction,such as SMAD 2/3 signaling). For example, a small molecule antagonist,or combination of small molecule antagonists, of the disclosure binds toan ActRIIB receptor and inhibits at least GDF11 from binding to and/oractivating the ActRIIB receptor. Optionally, such a small moleculeantagonist, or combination of small molecule antagonists, may furtherinhibit GDF8 from binding to and/or activating the ActRIIB receptor.Optionally, a small molecule antagonist, or combination of smallmolecule antagonists, of the disclosure does not substantially inhibitactivin A from binding to and/or activating an ActRIIB receptor. In someembodiments, a small molecule antagonist, or combination of smallmolecule antagonists, of the disclosure that inhibits GDF11 and/or GDF8from binding to and/or activating the ActRIIB receptor further inhibitsone or more of activin A, activin B, activin AB, activin C, activin E.BMP6, BMP7. and Nodal from binding to/and or activating the ActRIIBreceptor.

Binding organic small molecule antagonists of the present disclosure maybe identified and chemically synthesized using known methodology (see,e.g., PCT Publication Nos. WO 00/00823 and WO 00/39585). In general,small molecules antagonists of the disclosure are usually less thanabout 2000 daltons in size, alternatively less than about 1500, 750,500, 250 or 200 daltons in size, wherein such organic small moleculesthat are capable of binding, preferably specifically, to a polypeptideas described herein (e.g., GDF11, GDF8, ActRIIA, and ActRIIB). Suchsmall molecule antagonists may be identified without undueexperimentation using well known techniques. In this regard, it is notedthat techniques for screening organic small molecule libraries formolecules that are capable of binding to a polypeptide target are wellknown in the art. See, e.g., international patent publication Nos.WO00/00823 and WO00/39585.

Binding organic small molecules of the present disclosure may be, forexample, aldehydes, ketones, oximes, hydrazones, semicarbazones,carbazides, primary amines, secondary amines, tertiary amines,N-substituted hydrazines, hydrazides, alcohols, ethers, thiols,thioethers, disulfides, carboxylic acids, esters, amides, ureas,carbamates, carbonates, ketals, thioketals, acetals, thioacetals, arylhalides, aryl sulfonates, alkyl halides, alkyl sulfonates, aromaticcompounds, heterocyclic compounds, anilines, alkenes, alkynes, diols,amino alcohols, oxazolidines, oxazolines, thiazolidines, thiazolines,enamines, sulfonamides, epoxides, aziridines, isocyanates, sulfonylchlorides, diazo compounds, and acid chlorides.

Any of the small molecule ActRII antagonists disclosed herein (e.g., asmall molecule antagonist of one or more of GDF11, GDF8, activin A,activin B, activin AB, activin C, activin E. BMP6, BMP7, Nodal, ActRIIA,and/or ActRIIB) can be combined with one or more additional ActRIIantagonist agents of the disclosure to achieve the desired effect (e.g.,increase red blood cell levels and/or hemoglobin in a subject in needthereof, treat or prevent an anemia, treat sickle-cell disease, treat orprevent one or more complications of sickle-cell disease). For example,an small molecule ActRII antagonist disclosed herein (e.g., a smallmolecule antagonist of one or more of GDF11, GDF8, activin A, activin B.activin AB, activin C, activin E, BMP6, BMP7, Nodal, ActRIIA, and/orActRIIB) can be used in combination with i) one or more additional smallmolecule ActRII antagonists disclosed herein, ii) one or more ActRIIpolypeptides disclosed herein (e.g., ActRIIA and/or ActRIIBpolypeptides), iii) one or more GDF Traps disclosed herein; iv) one ormore ActRII antagonist antibodies disclosed herein (e.g., an anti-GDF11antibody, an anti-activin B antibody, an anti-activin C antibody, ananti-activin E antibody, an anti-GDF11 antibody, an anti-GDF8 antibody,an anti-BMP6 antibody, an-anti-BMP7 antibody, an anti-ActRIIA antibody,or an anti-ActRIIB antibody); v) one or more polynucleotide ActRIIantagonists disclosed herein (e.g., a polynucleotide antagonist of oneor more of GDF11, GDF8, activin A, activin B, activin AB, activin C,activin E, BMP6, BMP7. Nodal, ActRIIA, and/or ActRIIB); vi) one or morefollistatin polypeptides disclosed herein; and/or vii) one or more FLRGpolypeptides disclosed herein.

E. Antagonist Polynucleotides

In another aspect, the present disclosure relates to a polynucleotide,or combination of polynucleotides, that antagonizes ActRII activity(e.g., inhibition of ActRIIA and/or ActRIIB signaling transduction, suchas SMAD 2/3 and/or SMAD 1/5/8 signaling). In particular, the disclosureprovides methods of using a polynucleotide ActRII antagonist, orcombination of polynucleotide ActRII antagonists, to, e.g., treat orprevent an anemia in a subject in need thereof and/or treat or preventone or more complication of anemia including, for example, cutaneousulcers. In some embodiments, the disclosure provides methods of using apolynucleotide ActRII antagonist, or combination of polynucleotideActRII antagonists, to treat an anemia in a subject in need thereofand/or treat one or more complications of anemia including, for example,cutaneous ulcers, in a subject having anemia. In some embodiments, thedisclosure provides methods of using a polynucleotide ActRII antagonist,or combination of polynucleotide ActRII antagonists, to prevent ananemia in a subject in need thereof and/or prevent one or morecomplications of anemia including, for example, cutaneous ulcers in asubject having anemia.

In some embodiments, a polynucleotide ActRII antagonist, or combinationof polynucleotide ActRII antagonist, of the present disclosure can beused to inhibit the activity and/or expression of one or more of GDF11,GDF8, activin A, activin B, activin AB, activin C, activin C, activin E,BMP6, BMP7, Nodal, ActRIIA, and/or ActRIIB. In certain embodiments, apolynucleotide ActRII antagonist, or combination of polynucleotideActRII antagonist, of the disclosure is a GDF-ActRII antagonist.

In some embodiments, a polynucleotide antagonist, or combination ofpolynucleotide antagonists, of the disclosure inhibits the activityand/or expression (e.g., transcription, translation, secretion, orcombinations thereof) of at least GDF11. Optionally, such apolynucleotide antagonist, or combination of polynucleotide antagonists,may further inhibit the activity and/or expression of GDF8. Optionally,a polynucleotide antagonist, or combination of polynucleotideantagonists, of the disclosure does not substantially inhibit theactivity and/or expression of activin A. In some embodiments, apolynucleotide antagonist, or combination of polynucleotide antagonists,of the disclosure that inhibits the activity and/or expression of GDF11and/or GDF8 may further inhibit the activity and or expression of one ormore of activin A, activin B, activin AB, activin C, activin E, BMP6,BMP7, Nodal, ActRIIA, and/or ActRIIB.

In some embodiments, a polynucleotide antagonist, or combination ofpolynucleotide antagonists, of the disclosure inhibits the activityand/or expression (e.g., transcription, translation, secretion, orcombinations thereof) of at least GDF8. Optionally, such polynucleotideantagonist, or combination of polynucleotide antagonists, may furtherinhibit the activity and/or expression of GDF11. Optionally, apolynucleotide antagonist, or combination of polynucleotide antagonists,of the disclosure does not substantially inhibit the activity and/orexpression of activin A. In some embodiments, a polynucleotideantagonist, or combination of polynucleotide antagonists, of thedisclosure that inhibits the activity and/or expression of GDF8 and/orGDF11 may further inhibit the activity and or expression of one or moreof activin A, activin B, activin AB, activin C, activin E, BMP6, BMP7,Nodal, ActRIIA, and/or ActRIIB.

In some embodiments, a polynucleotide antagonist, or combination ofpolynucleotide antagonists, of the disclosure inhibits the activityand/or expression (e.g., transcription, translation, secretion, orcombinations thereof) of at least ActRIIA. Optionally, a polynucleotideantagonist, or combination of polynucleotide antagonists, of thedisclosure does not substantially inhibit the activity and/or expressionof activin A. In some embodiments, a polynucleotide antagonist, orcombination of polynucleotide antagonists, of the disclosure thatinhibits the activity and/or expression of ActRIIA may further inhibitthe activity and or expression of one or more of activin A, activin B,activin AB, activin C, activin E, BMP6, BMP7, Nodal, and/or ActRIIB.

In some embodiments, a polynucleotide antagonist, or combination ofpolynucleotide antagonists, of the disclosure inhibits the activityand/or expression (e.g., transcription, translation, secretion, orcombinations thereof) of at least ActRIIB. Optionally, a polynucleotideantagonist, or combination of polynucleotide antagonists, of thedisclosure does not substantially inhibit the activity and/or expressionof activin A. In some embodiments, a polynucleotide antagonist, orcombination of polynucleotide antagonists, of the disclosure thatinhibits the activity and/or expression of ActRIIB may further inhibitthe activity and or expression of one or more of activin A, activin B,activin AB, activin C, activin E, BMP6, BMP7, Nodal, and/or ActRIIA.

The polynucleotide antagonists of the present disclosure may be anantisense nucleic acid, an RNAi molecule (e.g., small interfering RNA(siRNA), small-hairpin RNA (shRNA), microRNA (miRNA)), an aptamer and/ora ribozyme. The nucleic acid and amino acid sequences of human GDF11,GDF8, activin A, activin B, activin C, activin E, BMP6, BMP7, Nodal,ActRIIA, and ActRIIB are known in the art and thus polynucleotideantagonists for use in accordance with methods of the present disclosuremay be routinely made by the skilled artisan based on the knowledge inthe art and teachings provided herein.

For example, antisense technology can be used to control gene expressionthrough antisense DNA or RNA, or through triple-helix formation.Antisense techniques are discussed, for example, in Okano (1991) J.Neurochem. 56:560; Oligodeoxynucleotides as Antisense Inhibitors of GeneExpression, CRC Press, Boca Raton, Fla. (1988). Triple helix formationis discussed in, for instance, Cooney et al. (1988) Science 241:456; andDervan et al., (1991) Science 251:1300. The methods are based on bindingof a polynucleotide to a complementary DNA or RNA. In some embodiments,the antisense nucleic acids comprise a single-stranded RNA or DNAsequence that is complementary to at least a portion of an RNAtranscript of a gene disclosed herein (e.g., GDF11, GDF8, activin A,activin B, activin C, activin C, activin E, BMP6, BMP7, Nodal, ActRIIA,and ActRIIB). However, absolute complementarity, is not required.

A sequence “complementary to at least a portion of an RNA,” referred toherein, means a sequence having sufficient complementarity to be able tohybridize with the RNA, forming a stable duplex; in the case of doublestranded antisense nucleic acids of a gene disclosed herein (e.g.,GDF11, GDF8, activin A, activin B, activin C, activin E, BMP6, BMP7,Nodal, ActRIIA, and ActRIIB), a single strand of the duplex DNA may thusbe tested, or triplex formation may be assayed. The ability to hybridizewill depend on both the degree of complementarity and the length of theantisense nucleic acid. Generally, the larger the hybridizing nucleicacid, the more base mismatches with an RNA it may contain and still forma stable duplex (or triplex as the case may be). One skilled in the artcan ascertain a tolerable degree of mismatch by use of standardprocedures to determine the melting point of the hybridized complex.

Polynucleotides that are complementary to the 5′ end of the message, forexample, the 5′ untranslated sequence up to and including the AUGinitiation codon, should work most efficiently at inhibitingtranslation. However, sequences complementary to the 3′ untranslatedsequences of mRNAs have been shown to be effective at inhibitingtranslation of mRNAs as well. See, e.g., Wagner, R., (1994) Nature372:333-335. Thus, oligonucleotides complementary to either the 5′-or3′-untranslated, non-coding regions of a gene of the disclosure (e.g.,GDF11, GDF8, activin A, activin B, activin C, activin E, BMP6, BMP7,Nodal, ActRIIA, and ActRIIB), could be used in an antisense approach toinhibit translation of an endogenous mRNA. Polynucleotides complementaryto the 5′ untranslated region of the mRNA should include the complementof the AUG start codon. Antisense polynucleotides complementary to mRNAcoding regions are less efficient inhibitors of translation but could beused in accordance with the methods of the present disclosure. Whetherdesigned to hybridize to the 5′-untranslated, 3′-untranslated or codingregion of an mRNA of the disclosure (e.g., an GDF11, GDF8. activin A,activin B, activin C, activin E, BMP6, BMP7, Nodal, ActRIIA, and ActRIIBmRNA), antisense nucleic acids should be at least six nucleotides inlength, and are preferably oligonucleotides ranging from 6 to about 50nucleotides in length. In specific aspects, the oligonucleotide is atleast 10 nucleotides, at least 17 nucleotides, at least 25 nucleotides,or at least 50 nucleotides.

In one embodiment, the antisense nucleic acid of the present disclosure(e.g., a GDF11, GDF8, activin A, activin B, activin C, activin E, BMP6,BMP7, Nodal, ActRIIA, or ActRIIB antisense nucleic acid) is producedintracellularly by transcription from an exogenous sequence. Forexample, a vector or a portion thereof, is transcribed, producing anantisense nucleic acid (RNA) of a gene of the disclosure. Such a vectorwould contain a sequence encoding the desired antisense nucleic acid.Such a vector can remain episomal or become chromosomally integrated, aslong as it can be transcribed to produce the desired antisense RNA. Suchvectors can be constructed by recombinant DNA technology methodsstandard in the art. Vectors can be plasmid, viral, or others known inthe art, used for replication and expression in vertebrate cells.Expression of the sequence encoding desired genes of the instantdisclosure, or fragments thereof, can be by any promoter known in theart to act in vertebrate, preferably human cells. Such promoters can beinducible or constitutive. Such promoters include, but are not limitedto, the SV40 early promoter region [see, e.g., Benoist and Chambon(1981) Nature 29:304-310], the promoter contained in the 3′ longterminal repeat of Rous sarcoma virus (see, e.g., Yamamoto et al. (1980)Cell 22:787-797, the herpes thymidine promoter [see, e.g., Wagner et al.(1981) Proc. Natl. Acad. Sci. U.S.A. 78:1441-1445], and the regulatorysequences of the metallothionein gene (see, e.g., Brinster, et al.(1982) Nature 296:39-42.

In some embodiments, the polynucleotide antagonists are interfering RNAor RNAi molecules that target the expression of one or more of: GDF11,GDF8, activin A, activin B, activin C, activin E, BMP6, BMP7, Nodal,ActRIIA, and ActRIIB. RNAi refers to the expression of an RNA whichinterferes with the expression of the targeted mRNA. Specifically, RNAisilences a targeted gene via interacting with the specific mRNA througha siRNA (small interfering RNA). The ds RNA complex is then targeted fordegradation by the cell. An siRNA molecule is a double stranded RNAduplex of 10 to 50 nucleotides in length, which interferes with theexpression of a target gene which is sufficiently complementary (e.g. atleast 80% identity to the gene). In some embodiments, the siRNA moleculecomprises a nucleotide sequence that is at least 85, 90, 95, 96, 97, 98,99, or 100% identical to the nucleotide sequence of the target gene.

Additional RNAi molecules include short hairpin RNA (shRNA); also shortinterfering hairpin and microRNA (miRNA). The shRNA molecule containssense and antisense sequences from a target gene connected by a loop.The shRNA is transported from the nucleus into the cytoplasm, and it isdegraded along with the mRNA. Pol III or U6 promoters can be used toexpress RNAs for RNAi. Paddison et al. [Genes & Dev. (2002) 16:948-958,2002] have used small RNA molecules folded into hairpins as a means toeffect RNAi. Accordingly, such short hairpin RNA (shRNA) molecules arealso advantageously used in the methods described herein. The length ofthe stem and loop of functional shRNAs varies; stem lengths can rangeanywhere from about 25 to about 30 nt, and loop size can range between 4to about 25 nt without affecting silencing activity. While not wishingto be bound by any particular theory, it is believed that these shRNAsresemble the double stranded RNA (dsRNA) products of the DICER RNaseand, in any event, have the same capacity for inhibiting expression of aspecific gene. The shRNA can be expressed from a lentiviral vector. AnmiRNA is a single stranded RNA of about 10 to 70 nucleotides in lengththat are initially transcribed as pre-miRNA characterized by a“stem-loop” structure and which are subsequently processed into maturemiRNA after further processing through the RISC.

Molecules that mediate RNAi, including without limitation siRNA, can beproduced in vitro by chemical synthesis (Hohjoh, FEBS Lett 521:195-199,2002), hydrolysis of dsRNA (Yang et al., Proc Natl Acad Sci USA99:9942-9947, 2002), by in vitro transcription with T7 RNA polymerase(Donzeet et al., Nucleic Acids Res 30:e46, 2002; Yu et al., Proc NatlAcad Sci USA 99:6047-6052, 2002), and by hydrolysis of double-strandedRNA using a nuclease such as E. coli RNase III (Yang et al., Proc NatlAcad Sci USA 99:9942-9947, 2002).

According to another aspect, the disclosure provides polynucleotideantagonists including but not limited to, a decoy DNA, a double strandedDNA, a single-stranded DNA, a complexed DNA, an encapsulated DNA, aviral DNA, a plasmid DNA, a naked RNA, an encapsulated RNA, a viral RNA,a double stranded RNA, a molecule capable of generating RNAinterference, or combinations thereof.

In some embodiments, the polynucleotide antagonists of the disclosureare aptamers. Aptamers are nucleic acid molecules, including doublestranded DNA and single stranded RNA molecules, which bind to and formtertiary structures that specifically bind to a target molecule, such asa GDF11, GDF8, activin A, activin B, activin C, activin E, BMP6, BMP7,Nodal, ActRIIA, and ActRIIB polypeptide. The generation and therapeuticuse of aptamers are well established in the art. See, e.g., U.S. Pat.No. 5,475,096. Additional information on aptamers can be found in U.S.Patent Application Publication No. 20060148748. Nucleic acid aptamersare selected using methods known in the art, for example via theSystematic Evolution of Ligands by Exponential Enrichment (SELEX)process. SELEX is a method for the in vitro evolution of nucleic acidmolecules with highly specific binding to target molecules as describedin, e.g., U.S. Pat. Nos. 5,475,096, 5,580,737, 5,567,588, 5,707,796,5,763,177, 6,011,577, and 6,699,843.

Another screening method to identify aptamers is described in U.S. Pat.No. 5,270,163. The SELEX process is based on the capacity of nucleicacids for forming a variety of two-and three-dimensional structures, aswell as the chemical versatility available within the nucleotidemonomers to act as ligands (form specific binding pairs) with virtuallyany chemical compound, whether monomeric or polymeric, including othernucleic acid molecules and polypeptides.

Molecules of any size or composition can serve as targets. The SELEXmethod involves selection from a mixture of candidate oligonucleotidesand step-wise iterations of binding, partitioning and amplification,using the same general selection scheme, to achieve desired bindingaffinity and selectivity. Starting from a mixture of nucleic acids,which can comprise a segment of randomized sequence, the SELEX methodincludes steps of contacting the mixture with the target underconditions favorable for binding; partitioning unbound nucleic acidsfrom those nucleic acids which have bound specifically to targetmolecules; dissociating the nucleic acid-target complexes; amplifyingthe nucleic acids dissociated from the nucleic acid-target complexes toyield a ligand enriched mixture of nucleic acids. The steps of binding,partitioning, dissociating and amplifying are repeated through as manycycles as desired to yield highly specific high affinity nucleic acidligands to the target molecule.

Typically, such binding molecules are separately administered to theanimal [see, e.g., O'Connor (1991) J. Neurochem. 56:560], but suchbinding molecules can also be expressed in vivo from polynucleotidestaken up by a host cell and expressed in vivo. See, e.g.,Oligodeoxynucleotides as Antisense Inhibitors of Gene Expression, CRCPress, Boca Raton, Fla. (1988).

Any of the polynucleotide ActRII antagonists disclosed herein (e.g., apolynucleotide antagonist of one or more of GDF11, GDF8, activin A,activin B, activin AB, activin C, activin E, BMP6, BMP7, Nodal, ActRIIA,and/or ActRIIB) can be combined with one or more additional ActRIIantagonist agents of the disclosure to achieve the desired effect (e.g.,treat or prevent an anemia in a subject in need thereof and/or treat orprevent one or more complications of anemia including, for example,cutaneous ulcers). For example, an polynucleotide ActRII antagonistdisclosed herein (e.g., a polynucleotide antagonist of one or more ofGDF11, GDF8, activin A, activin B, activin AB, activin C, activin E,BMP6, BMP7, Nodal, ActRIIA, and/or ActRIIB) can be used in combinationwith i) one or more additional polynucleotide ActRII antagonistsdisclosed herein, ii) one or more ActRII polypeptides disclosed herein(e.g., ActRIIA and/or ActRIIB polypeptides), iii) one or more GDF Trapsdisclosed herein; iv) one or more ActRII antagonist antibodies disclosedherein (e.g., an anti-GDF11 antibody, an anti-activin B antibody, ananti-activin C antibody, an anti-activin E antibody, an anti-GDF11antibody, an anti-GDF8 antibody, an anti-BMP6 antibody, an-anti-BMP7antibody, an anti-ActRIIA antibody, or an anti-ActRIIB antibody); v) oneor more small molecule ActRII antagonists disclosed herein (e.g., asmall molecule antagonist of one or more of GDF11, GDF8, activin A,activin B, activin AB, activin C, activin E, BMP6, BMP7, Nodal, ActRIIA,and/or ActRIIB); vi) one or more follistatin polypeptides disclosedherein; and/or vii) one or more FLRG polypeptides disclosed herein.

F. Other Antagonists

In other aspects, an agent for use in accordance with the methodsdisclosed herein (e.g., methods of treating or preventing an anemia inan subject in need thereof and/or methods of treating or preventing oneor more complications of anemia including, for example, cutaneousulcers) is a follistatin polypeptide. The term “follistatin polypeptide”includes polypeptides comprising any naturally occurring polypeptide offollistatin as well as any variants thereof (including mutants,fragments, fusions, and peptidomimetic forms) that retain a usefulactivity, and further includes any functional monomer or multimer offollistatin. In certain embodiments, follistatin polypeptides of thedisclosure bind to and/or inhibit activin activity, particularly activinA (e.g., activin-mediated activation of ActRIIA and/or ActRIIB SMAD 2/3signaling). Variants of follistatin polypeptides that retain activinbinding properties can be identified based on previous studies involvingfollistatin and activin interactions. For example, WO2008/030367discloses specific follistatin domains (“FSDs”) that are shown to beimportant for activin binding. As shown below in SEQ ID NOs: 18-20, thefollistatin N-terminal domain (“FSND” SEQ ID NO:18), FSD2 (SEQ ID NO:20), and to a lesser extent FSD1 (SEQ ID NO: 19) represent exemplarydomains within follistatin that are important for activin binding. Inaddition, methods for making and testing libraries of polypeptides aredescribed above in the context of ActRII polypeptides and such methodsalso pertain to making and testing variants of follistatin. Follistatinpolypeptides include polypeptides derived from the sequence of any knownfollistatin having a sequence at least about 80% identical to thesequence of a follistatin polypeptide, and optionally at least 85%, 90%,95%, 96%, 97%, 98%, 99% or greater identity. Examples of follistatinpolypeptides include the mature follistatin polypeptide or shorterisoforms or other variants of the human follistatin precursorpolypeptide (SEQ ID NO: 16) as described, for example, in WO2005/025601.

The human follistatin precursor polypeptide isoform FST344 is asfollows:

(SEQ ID NO: 16; NCBI Reference No. NP_037541.1 follistatin isoformFST344) 1 mvrarhqpgg lcllllllcq fmedrsaqag ncwlrqakng rcqvlyktel 51skeeccstgr lstswteedv ndntlfkwmi fnggapncip cketcenvdc 101 gpgkkcrmnkknkprcvcap dcsnitwkgp vcgldgktyr necallkarc 151 keqpelevqy qgrckktcrdvfcpgsstcv vdqtnnaycv tcnricpepa 201 sseqylcgnd gvtyssachl rkatcllgrsiglayegkci kakscediqc 251 tggkkclwdf kvgrgrcslc delcpdsksd epvcasdnatyasecamkea 301 acssgvllev khsgscnsis edteeeeede dqdysfpiss ilew

The signal peptide is underlined; also underlined above are the last 27residues in which represent the C-terminal extension distinguishing thisfollistatin isoform from the shorter follistatin isoform FST317 shownbelow.

The human follistatin precursor polypeptide isoform FST317 is asfollows:

(SEQ ID NO: 17; NCBI Reference No. NP_006341.1) 1MVRARHQPGG LCLLLLLLCQ FMEDRSAQAG NCWLRQAKNG RCQVLYKTEL 51 SKEECCSTGRLSTSWTEEDV NDNTLFKWMI FNGGAPNCIP CKETCENVDC 101 GPGKKCRMNK KNKPRCVCAPDCSNITWKGP VCGLDGKTYR NECALLKARC 151 KEQPELEVQY QGRCKKTCRD VFCPGSSTCVVDQTNNAYCV TCNRICPEPA 201 SSEQYLCGND GVTYSSACHL RKATCLLGRS IGLAYEGKCIKAKSCEDIQC 251 TGGKKCLWDF KVGRGRCSLC DELCPDSKSD EPVCASDNAT YASECAMKEA301 ACSSGVLLEV KHSGSCNThe signal peptide is underlined.

The follistatin N-terminus domain (FSND) sequence is as follows:

(SEQ ID NO: 18; FSND) GNCWLRQAKNGRCQVLYKTELSKEECCSTGRLSTSWTEEDVNDNTLFKWMIFNGGAPNCIPCK

The FSD1 and FSD2 sequences are as follows:

(SEQ ID NO: 19; FSD1) ETCENVDCGPGKKCRMNKKNKPRCV (SEQ ID NO: 20; FSD2)KTCRDVFCPGSSTCVVDQTNNAYCVT

In other aspects, an agent for use in accordance with the methodsdisclosed herein (e.g., methods of treating or preventing an anemia inan subject in need thereof and/or methods of treating or preventing acomplication of anemia including, for example, cutaneous ulcers) is afollistatin-like related gene (FLRG), also known as follistatin-relatedprotein 3 (FSTL3). In some embodiments, the agent is used to treat acomplication of anemia including, for example, cutaneous ulcers. In someembodiments, the agent is used to prevent a complication of anemiaincluding, for example, cutaneous ulcers. The term “FLRG polypeptide”includes polypeptides comprising any naturally occurring polypeptide ofFLRG as well as any variants thereof (including mutants, fragments,fusions, and peptidomimetic forms) that retain a useful activity. Incertain embodiments, FLRG polypeptides of the disclosure bind to and/orinhibit activin activity, particularly activin A (e.g., activin-mediatedactivation of ActRIIA and/or ActRIIB SMAD 2/3 signaling). Variants ofFLRG polypeptides that retain activin binding properties can beidentified using routine methods to assay FLRG and activin interactions.See, e.g., U.S. Pat. No. 6,537,966. In addition, methods for making andtesting libraries of polypeptides are described above in the context ofActRII polypeptides and such methods also pertain to making and testingvariants of FLRG. FLRG polypeptides include polypeptides derived fromthe sequence of any known FLRG having a sequence at least about 80%identical to the sequence of an FLRG polypeptide, and optionally atleast 85%, 90%, 95%, 97%, 99% or greater identity.

The human FLRG (follistatin-related protein 3 precursor) polypeptide isas follows:

(SEQ ID NO: 21; NCBI Reference No. NP_005851.1) 1MRPGAPGPLW PLPWGALAWA VGFVSSMGSG NPAPGGVCWL QQGQEATCSL 51 VLQTDVTRAECCASGNIDTA WSNLTHPGNK INLLGFLGLV HCLPCKDSCD 101 GVECGPGKAC RMLGGRPRCECAPDCSGLPA RLQVCGSDGA TYRDECELRA 151 ARCRGHPDLS VMYRGRCRKS CEHVVCPRPQSCVVDQTGSA HCVVCRAAPC 201 PVPSSPGQEL CGNNNVTYIS SCHMRQATCF LGRSIGVRHAGSCAGTPEEP 251 PGGESAEEEE NFVThe signal peptide is underlined.

In certain embodiments, functional variants or modified forms of thefollistatin polypeptides and FLRG polypeptides include fusion proteinshaving at least a portion of the follistatin polypeptides or FLRGpolypeptides and one or more fusion domains, such as, for example,domains that facilitate isolation, detection, stabilization ormultimerization of the polypeptide. Suitable fusion domains arediscussed in detail above with reference to the ActRII polypeptides. Insome embodiment, an antagonist agent of the disclosure is a fusionprotein comprising an activin-binding portion of a follistatinpolypeptide fused to an Fc domain. In another embodiment, an antagonistagent of the disclosure is a fusion protein comprising an activinbinding portion of an FLRG polypeptide fused to an Fc domain.

Any of the follistatin polypeptides disclosed herein may be combinedwith one or more additional ActRII antagonist agents of the disclosureto achieve the desired effect (e.g., treat or prevent an anemia in asubject in need thereof and/or treat or prevent one or morecomplications of anemia including, for example, cutaneous ulcers). Forexample, a follistatin polypeptide disclosed herein can be used incombination with i) one or more additional follistatin polypeptidesdisclosed herein, ii) one or more ActRII polypeptides disclosed herein(e.g., ActRIIA and/or ActRIIB polypeptides), iii) one or more GDF Trapsdisclosed herein; iv) one or more ActRII antagonist antibodies disclosedherein (e.g., an anti-GDF11 antibody, an anti-activin B antibody, ananti-activin C antibody, an anti-activin E antibody, an anti-GDF11antibody, an anti-GDF8 antibody, an anti-BMP6 antibody, an-anti-BMP7antibody, an anti-ActRIIA antibody, or an anti-ActRIIB antibody); v) oneor more small molecule ActRII antagonists disclosed herein (e.g., asmall molecule antagonist of one or more of GDF11, GDF8, activin A,activin B, activin AB, activin C, activin E, BMP6, BMP7, Nodal, ActRIIA,and/or ActRIIB); vi) one or more polynucleotide ActRII antagonistsdisclosed herein (e.g., a polynucleotide antagonist of one or more ofGDF11, GDF8, activin A, activin B, activin AB, activin C, activin E,BMP6, BMP7, Nodal, ActRIIA, and/or ActRIIB); and/or one or more FLRGpolypeptides disclosed herein.

Similarly, any of the FLRG polypeptides disclosed herein may be combinedwith one or more additional ActRII antagonist agents of the disclosureto achieve the desired effect (e.g., treat or prevent an anemia in asubject in need thereof and/or treat or prevent one or morecomplications of anemia including, for example, cutaneous ulcers). Forexample, a FLRG polypeptide disclosed herein can be used in combinationwith i) one or more additional FLRG polypeptides disclosed herein, ii)one or more ActRII polypeptides disclosed herein (e.g., ActRIIA and/orActRIIB polypeptides), iii) one or more GDF Traps disclosed herein; iv)one or more ActRII antagonist antibodies disclosed herein (e.g., ananti-GDF11 antibody, an anti-activin B antibody, an anti-activin Cantibody, an anti-activin E antibody, an anti-GDF11 antibody, ananti-GDF8 antibody, an anti-BMP6 antibody, an-anti-BMP7 antibody, ananti-ActRIIA antibody, or an anti-ActRIIB antibody); v) one or moresmall molecule ActRII antagonists disclosed herein (e.g., a smallmolecule antagonist of one or more of GDF11, GDF8, activin A, activin B,activin AB, activin C, activin E, BMP6, BMP7, Nodal, ActRIIA, and/orActRIIB); vi) one or more polynucleotide ActRII antagonists disclosedherein (e.g., a polynucleotide antagonist of one or more of GDF11, GDF8,activin A, activin B, activin AB, activin C, activin E, BMP6, BMP7,Nodal, ActRIIA, and/or ActRIIB); and/or one or more follistatinpolypeptides disclosed herein.

4. Screening Assays

In certain aspects, the present disclosure relates to the use of thesubject ActRII polypeptides (e.g., ActRIIA and ActRIIB polypeptides) andGDF Trap polypeptides to identify compounds (agents) which are agonistor antagonists of ActRIIB polypeptides. Compounds identified throughthis screening can be tested to assess their ability to modulate redblood cell, hemoglobin, and/or reticulocyte levels as well as effectcutaneous ulcers. These compounds can be tested, for example, in animalmodels.

There are numerous approaches to screening for therapeutic agents forincreasing red blood cell or hemoglobin levels by targeting ActRIIsignaling (e.g., ActRIIA and/or ActRIIB SMAD 2/3 and/or SMAD 1/5/8signaling). In certain embodiments, high-throughput screening ofcompounds can be carried out to identify agents that perturbActRII-mediated effects on a selected cell line. In certain embodiments,the assay is carried out to screen and identify compounds thatspecifically inhibit or reduce binding of an ActRII polypeptide or GDFTrap polypeptide to its binding partner, such as an ActRII ligand (e.g.,activin A, activin B, activin AB, activin C, Nodal, GDF8, GDF11 orBMP7). Alternatively, the assay can be used to identify compounds thatenhance binding of an ActRII polypeptide or GDF Trap polypeptide to itsbinding partner such as an ActRII ligand. In a further embodiment, thecompounds can be identified by their ability to interact with an ActRIIpolypeptide or GDF Trap polypeptide.

A variety of assay formats will suffice and, in light of the presentdisclosure, those not expressly described herein will nevertheless becomprehended by one of ordinary skill in the art. As described herein,the test compounds (agents) of the invention may be created by anycombinatorial chemical method. Alternatively, the subject compounds maybe naturally occurring biomolecules synthesized in vivo or in vitro.Compounds (agents) to be tested for their ability to act as modulatorsof tissue growth can be produced, for example, by bacteria, yeast,plants or other organisms (e.g., natural products), produced chemically(e.g., small molecules, including peptidomimetics), or producedrecombinantly. Test compounds contemplated by the present inventioninclude non-peptidyl organic molecules, peptides, polypeptides,peptidomimetics, sugars, hormones, and nucleic acid molecules. Incertain embodiments, the test agent is a small organic molecule having amolecular weight of less than about 2,000 Daltons.

The test compounds of the disclosure can be provided as single, discreteentities, or provided in libraries of greater complexity, such as madeby combinatorial chemistry. These libraries can comprise, for example,alcohols, alkyl halides, amines, amides, esters, aldehydes, ethers andother classes of organic compounds. Presentation of test compounds tothe test system can be in either an isolated form or as mixtures ofcompounds, especially in initial screening steps. Optionally, thecompounds may be optionally derivatized with other compounds and havederivatizing groups that facilitate isolation of the compounds.Non-limiting examples of derivatizing groups include biotin,fluorescein, digoxygenin, green fluorescent protein, isotopes,polyhistidine, magnetic beads, glutathione S transferase (GST),photoactivatable crosslinkers or any combinations thereof.

In many drug screening programs which test libraries of compounds andnatural extracts, high throughput assays are desirable in order tomaximize the number of compounds surveyed in a given period of time.Assays which are performed in cell-free systems, such as may be derivedwith purified or semi-purified proteins, are often preferred as“primary” screens in that they can be generated to permit rapiddevelopment and relatively easy detection of an alteration in amolecular target which is mediated by a test compound. Moreover, theeffects of cellular toxicity or bioavailability of the test compound canbe generally ignored in the in vitro system, the assay instead beingfocused primarily on the effect of the drug on the molecular target asmay be manifest in an alteration of binding affinity between an ActRIIpolypeptide or a GDF Trap polypeptide and its binding partner (e.g., anActRII ligand).

Merely to illustrate, in an exemplary screening assay of the presentdisclosure, the compound of interest is contacted with an isolated andpurified ActRIIB polypeptide which is ordinarily capable of binding toan ActRIIB ligand, as appropriate for the intention of the assay. To themixture of the compound and ActRIIB polypeptide is then added to acomposition containing an ActRIIB ligand (e.g., GDF11). Detection andquantification of ActRIIB/ActRIIB ligand complexes provides a means fordetermining the compound's efficacy at inhibiting (or potentiating)complex formation between the ActRIIB polypeptide and its bindingprotein. The efficacy of the compound can be assessed by generating doseresponse curves from data obtained using various concentrations of thetest compound. Moreover, a control assay can also be performed toprovide a baseline for comparison. For example, in a control assay,isolated and purified ActRIIB ligand is added to a compositioncontaining the ActRIIB polypeptide, and the formation of ActRIIB/ActRIIBligand complex is quantitated in the absence of the test compound. Itwill be understood that, in general, the order in which the reactantsmay be admixed can be varied, and can be admixed simultaneously.Moreover, in place of purified proteins, cellular extracts and lysatesmay be used to render a suitable cell-free assay system.

Complex formation between an ActRII polypeptide or GDF Trap polypeptideand its binding protein may be detected by a variety of techniques. Forinstance, modulation of the formation of complexes can be quantitatedusing, for example, detectably labeled proteins such as radiolabeled(e.g., ³²P, ³⁵S, ¹⁴C or ³H), fluorescently labeled (e.g., FITC), orenzymatically labeled ActRII polypeptide or GDF Trap polypeptide and/orits binding protein, by immunoassay, or by chromatographic detection.

In certain embodiments, the present disclosure contemplates the use offluorescence polarization assays and fluorescence resonance energytransfer (FRET) assays in measuring, either directly or indirectly, thedegree of interaction between an ActRII polypeptide of GDF Trappolypeptide and its binding protein. Further, other modes of detection,such as those based on optical waveguides (see, e.g., PCT Publication WO96/26432 and U.S. Pat. No. 5,677,196), surface plasmon resonance (SPR),surface charge sensors, and surface force sensors, are compatible withmany embodiments of the disclosure.

Moreover, the present disclosure contemplates the use of an interactiontrap assay, also known as the “two hybrid assay,” for identifying agentsthat disrupt or potentiate interaction between an ActRII polypeptide orGDF Trap polypeptide and its binding partner. See, e.g., U.S. Pat. No.5,283,317; Zervos et al. (1993) Cell 72:223-232; Madura et al. (1993) JBiol Chem 268:12046-12054; Bartel et al. (1993) Biotechniques14:920-924; and Iwabuchi et al. (1993) Oncogene 8:1693-1696). In aspecific embodiment, the present disclosure contemplates the use ofreverse two hybrid systems to identify compounds (e.g., small moleculesor peptides) that dissociate interactions between an ActRII polypeptideor GDF Trap and its binding protein. See, e.g., Vidal and Legrain,(1999) Nucleic Acids Res 27:919-29; Vidal and Legrain, (1999) TrendsBiotechnol 17:374-81; and U.S. Pat. Nos. 5,525,490; 5,955,280; and5,965,368.

In certain embodiments, the subject compounds are identified by theirability to interact with an ActRII polypeptide or GDF Trap polypeptide.The interaction between the compound and the ActRII polypeptide or GDFTrap polypeptide may be covalent or non-covalent. For example, suchinteraction can be identified at the protein level using in vitrobiochemical methods, including photo-crosslinking, radiolabeled ligandbinding, and affinity chromatography. See, e.g., Jakoby W B et al.(1974) Methods in Enzymology 46:1. In certain cases, the compounds maybe screened in a mechanism based assay, such as an assay to detectcompounds which bind to an ActRII polypeptide of GDF Trap polypeptide.This may include a solid phase or fluid phase binding event.Alternatively, the gene encoding an ActRII polypeptide or GDF Trappolypeptide can be transfected with a reporter system (e.g.,β-galactosidase, luciferase, or green fluorescent protein) into a celland screened against the library preferably by a high throughputscreening or with individual members of the library. Other mechanismbased binding assays may be used, for example, binding assays whichdetect changes in free energy. Binding assays can be performed with thetarget fixed to a well, bead or chip or captured by an immobilizedantibody or resolved by capillary electrophoresis. The bound compoundsmay be detected usually using colorimetric endpoints or fluorescence orsurface plasmon resonance.

5. Exemplary Therapeutic Uses

In certain aspects, an ActRII antagonist agent, or combination of ActRIIantagonist agents, of the present disclosure can be used to increase redblood cell levels in a subject (e.g., a patient) in need thereof,particularly mammals such as rodents, primates, and humans. In someembodiments, an ActRII antagonist agent, or combination of ActRIIantagonist agents, of the present disclosure can be used to treat orprevent an anemia in a subject (e.g., a patient) in need thereof and/orone or more complications of anemia including, for example, an ulcer,particularly a cutaneous ulcer. In some embodiments, an ActRIIantagonist agent, or combination of ActRII antagonist agents, of thepresent disclosure can be used to treat an anemia in a subject (e.g., apatient) in need thereof and/or one or more complications of anemiaincluding, for example, an ulcer, particularly a cutaneous ulcer. Insome embodiments, an ActRII antagonist agent, or combination of ActRIIantagonist agents, of the present disclosure can be used to prevent ananemia in a subject (patient) in need thereof and/or one or morecomplications of anemia including, for example, an ulcer, particularly acutaneous ulcer. In some embodiments, an ActRII antagonist agent, orcombination of ActRII antagonist agents, of the present disclosure canbe used to treat or prevent an ulcer in a subject (e.g., a patient)having anemia, particularly mammals such as rodents, primates, andhumans. In some embodiments, an ActRII antagonist agent, or combinationof ActRII antagonist agents, of the present disclosure can be used totreat or prevent an ulcer that is associated with anemia in a subject(e.g., a patient) in need thereof, particularly mammals such as rodents,primates, and humans. In some embodiments, an ActRII antagonist agent,or combination of ActRII antagonist agents, of the present disclosurecan be used to treat or prevent a cutaneous (e.g., skin) ulcer in asubject (e.g., a patient) having anemia, particularly mammals such asrodents, primates, and humans. In some embodiments, an ActRII antagonistagent, or combination of ActRII antagonist agents, of the presentdisclosure can be used to treat or prevent a cutaneous ulcer associatedwith anemia in a subject (e.g., patient) in need thereof, particularlymammals such as rodents, primates, and humans. In some embodiments, anActRII antagonist agent, or combination of ActRII antagonist agents, ofthe present disclosure can be used to treat or prevent an ulcer (e.g., acutaneous ulcer) in a subject (e.g., patient) having a hemolytic anemia,particularly mammals such as rodents, primates, and humans. In someembodiments, an ActRII antagonist agent, or combination of ActRIIantagonist agents, of the present disclosure can be used to treat orprevent an ulcer (e.g., a cutaneous ulcer) in a subject (e.g., patient)having a hemoglobinopathy anemia, particularly mammals such as rodents,primates, and humans. In some embodiments, an ActRII antagonist agent,or combination of ActRII antagonist agents, of the present disclosurecan be used to treat or prevent an ulcer (e.g., a cutaneous ulcer) in asubject (patient) having a thalassemia syndrome (e.g., β-thalassemiasyndrome, β-thalassemia intermedia, etc.), particularly mammals such asrodents, primates, and humans. In some embodiments, an ActRII antagonistagent, or combination of ActRII antagonist agents, of the presentdisclosure can be used to treat or prevent an ulcer (e.g., a cutaneousulcer) in a subject (patient) having sickle-cell disease, particularlymammals such as rodents, primates, and humans. In some of the foregoingembodiments, the ActRII antagonist agent, or combination of ActRIIantagonist agents, of the present disclosure are used to treat an ulcer(e.g., a cutaneous ulcer) in a subject (e.g., patient) having anemia(e.g., hemolytic anemia, hemoglobinopathy anemia, a thalassemia syndrome(e.g., β-thalassemia syndrome, β-thalassemia intermedia, etc.),sickle-cell disease, etc.). In some of the foregoing embodiments, theActRII antagonist agent, or combination of ActRII antagonist agents, ofthe present disclosure are used to prevent an ulcer (e.g., a cutaneousulcer) in a subject (e.g., patient) having anemia (e.g., hemolyticanemia, hemoglobinopathy anemia, a thalassemia syndrome (e.g.,β-thalassemia syndrome, β-thalassemia intermedia, etc.), sickle-celldisease, etc.). In some embodiments, the subject having anemia hassickle cell disease. In some embodiments, the subject having anemia hasa thalassemia syndrome (e.g., β-thalassemia syndrome, β-thalassemiaintermedia, etc.). In some embodiments, the subject having anemia has acutaneous ulcer. In some embodiments, the cutaneous ulcer is a skinulcer. In some embodiments, the ulcer occurs on legs or ankles.

As used herein, a therapeutic that “prevents” a disorder or conditionrefers to a compound that, in a statistical sample, reduces theoccurrence of the disorder or condition in the treated sample relativeto an untreated control sample, or delays the onset or reduces theseverity of one or more symptoms of the disorder or condition relativeto the untreated control sample. For example, using an ActRII antagonistof the disclosure to prevent an ulcer (e.g., cutaneous ulcer) in asubject having anemia refers to reducing the occurrence of ulcer in thesubject or delays the onset or reduces the severity of ulcer in thesubject relative to a subject having anemia who is not receiving anActRII antagonist.

The term “treating” as used herein includes amelioration or eliminationof the condition once it has been established. In either case,prevention or treatment may be discerned in the diagnosis provided by aphysician or other health care provider and the intended result ofadministration of the therapeutic agent. In some embodiments, treatingan ulcer refers to promoting wound healing of ulcer tissues.

In general, treatment or prevention of a disease or condition asdescribed in the present disclosure is achieved by administering one ormore of the ActRII antagonists (e.g., an ActRIIA and/or ActRIIBantagonist) of the present disclosure in an effective amount. Aneffective amount of an agent refers to an amount effective, at dosagesand for periods of time necessary, to achieve the desired therapeutic orprophylactic result. A “therapeutically effective amount” of an agent ofthe present disclosure may vary according to factors such as the diseasestate, age, sex, and weight of the individual, and the ability of theagent to elicit a desired response in the individual. A“prophylactically effective amount” refers to an amount effective, atdosages and for periods of time necessary, to achieve the desiredprophylactic result.

Ulcers and Anemia

An ulcer is a sore on the skin or mucous membrane which is accompaniedby the disintegration of tissue. Cutaneous (skin) ulcers can result incomplete loss of epidermis and often portions of the dermis and evensubcutaneous fat. Cutaneous ulcers are most common on the skin of thelower extremities but do occur on other areas of the body. Typically,ulcers appear as open craters, often round, with layers of skin thathave eroded, and such lesions are highly susceptible to infection. Theskin around the ulcer may be red, swollen, and/or tender. In general,ulcers tend to heal more slowly that other types of skin injuries andare resistant to treatment.

Ulcers develop in stages. In stage 1, the skin is red with softunderlying tissue. In the second stage, the redness of the skin becomesmore pronounced, swelling appears, and there may be some blisters andloss of outer skin layers. During the next stage, the skin may becomenecrotic down through the deep layer of the skin, and the fat beneathmay become exposed. In the last two stages, the sore may cause a deeperloss of fat and necrosis of muscle—in serve cases, it can extend todestruction of the bone and cause sepsis. In view of staged progressionof ulcer pathology, physicians have adopted grading systems to classifyulcers. The Wagner Grading System classifies ulcers into 5 categories:i) a superficial ulcer is designated as Grade 1; ii) a ulcer deeper intosubcutaneous tissue exposing soft tissue (but no abscess orosteomyelitis) is designated as Grade 2; iii) an ulcer with abscessformation and/or osteomyelitis is designated as Grade 3; iv) an ulcerhaving associated gangrene on part of a tissue or limb is designated asGrade 4; and v) an ulcer having extensive gangrene to a large area orentire limb is designated as Grade 5.

Ulcers, particularly cutaneous ulcers, occur as a complication of manyanemias. In most patients, these ulcers occur in the legs or ankles, butmay occur on other parts of the body. The relationship between anemiaand ulcer formation is multifactorial, but it is generally expected thatelevated hemolysis, oxidative stress, poor tissue oxygenation andvascular congestion may all contribute to the formation of ulcers.Elevated hemolysis causes the release of free hemoglobin into the serum,which causes oxidative damage and consumes nitric oxide that is neededto maintain proper vascular tone. Ulcers are associated with manyhereditary and acquired anemias, including hereditary spherocytosis,hereditary elliptocytosis, hereditary stomacytosis, glucose6-phosphatedehydrogenase deficiency, sickle cell disease, thalassemia (both alphaand beta), paroxysmal nocturnal hemoglobinuria. Sickle cell disease andthe thalassemias are particularly noted for causing ulcers, probablybecause all of the risk factors are present in these diseases. Ulcersare associated with many hemolytic anemias, which describes an anemiccondition that results from excessive destruction of red blood cells.Hemolytic anemias may result from infections, such as hepatitis,cytomegalovirus (CMV), Epstein-Barr virus (EBV), typhoid fever, E. coli(escherichia coli), mycoplasma pneumonia, or streptococcus, medications,such as penicillin, antimalaria medications, sulfa medications, oracetaminophen, cancers such as leukemia or lymphoma and solid tumors ofvarious types, autoimmune disorders, such as systemic lupus erythematous(SLE, or lupus), rheumatoid arthritis, Wiskott-Aldrich syndrome, orulcerative colitis, hypersplenism, and autoimmune hemolytic anemia, inwhich the body's immune system creates an antibody against its own bloodcells. Microangiopathic hemolytic anemia and thrombotic thrombocytopenicpurpura are also associated with anemia and ulcer formation.

In some embodiments, an ActRII antagonist agent, or combination ofActRII antagonist agents, of the present disclosure can be used to treator prevent an ulcer (e.g., a cutaneous ulcer) in a subject (patient)having an anemia selected from: including hereditary spherocytosis,hereditary elliptocytosis, hereditary stomacytosis, glucose6-phosphatedehydrogenase deficiency, a hemolytic anemia, a hemoglobinopathy anemia,sickle-cell disease, thalassemia (both alpha and beta), a β-thalassemiasyndrome, β-thalassemia intermedia, paroxysmal nocturnal hemoglobinuria,microangiopathic hemolytic anemia, thrombotic thrombocytopenic purpra,an anemia associated with an infection (e.g., hepatitis, cytomegalovirus(CMV), Epstein-Barr virus (EBV), typhoid fever, E. coli (escherichiacoli), mycoplasma pneumonia, or streptococcus), an anemia associatedwith administration of a medication (e.g., penicillin, antimalariamedications, sulfa medications, or acetaminophen), anemia associatedwith a cancer (e.g., leukemia, lymphoma, and solid tumors of varioustypes), and anemia associated with an autoimmune disorder (e.g.,systemic lupus erythematous (SLE, or lupus), rheumatoid arthritis,Wiskott-Aldrich syndrome, or ulcerative colitis, hypersplenism, andautoimmune hemolytic anemia, in which the body's immune system createsan antibody against its own blood cells). In some embodiments, an ActRIIantagonist agent, or combination of ActRII antagonist agents, of thepresent disclosure can be used to treat or prevent an ulcer (e.g., acutaneous ulcer) in a subject (patient) having a hemolytic anemia. Insome embodiments, an ActRII antagonist agent, or combination of ActRIIantagonist agents, of the present disclosure can be used to treat orprevent an ulcer (e.g., a cutaneous ulcer) in a subject (patient) havinga hemoglobinopathy anemia. In some embodiments, an ActRII antagonistagent, or combination of ActRII antagonist agents, of the presentdisclosure can be used to treat or prevent an ulcer (e.g., a cutaneousulcer) in a subject (patient) having a thalassemia syndrome. In someembodiments, an ActRII antagonist agent, or combination of ActRIIantagonist agents, of the present disclosure can be used to treat orprevent an ulcer (e.g., a cutaneous ulcer) in a subject (patient) havinga β-thalassemia syndrome. In some embodiments, an ActRII antagonistagent, or combination of ActRII antagonist agents, of the presentdisclosure can be used to treat or prevent an ulcer (e.g., a cutaneousulcer) in a subject (patient) having R-thalassemia intermedia. In someembodiments, an ActRII antagonist agent, or combination of ActRIIantagonist agents, of the present disclosure can be used to improve theGrade classification (e.g., the Wager Grading System) of the ulcer(e.g., a cutaneous ulcer) by at least one Grade (e.g., by at least one,two, three, four, or five Grades).

In certain embodiments, one or more ActRII antagonist agents of thedisclosure (e.g., a GDF-ActRII antagonist, an ActRIIA polypeptide, anActRIIB polypeptide, a GDF Trap, etc.) may be used in combination withsupportive therapies for ulcers. Conventional care of cutaneous ulcersinvolves debridement and cleansing of the wound followed by applicationof occlusive dressing. See, e.g., Marti-Carvajal et al (2012) TheCochrane Collaboration, Published by Wiley & Sons, Ltd. Additionalinterventions can generally be classified into two major treatmentgroups: pharmaceutical interventions (systemic and topical agents) andnon-pharmaceutical interventions. Systemic pharmaceutical interventionsinclude, for example, vascular drugs (e.g., pentoxifylline, isoxsuprinehydrochloride, and xanthinol nicotinate), antioxidant agents (e.g.,L-carnitine), EPO and EPO-stimulating agents, growth factors (e.g.,Bosentan), minerals (e.g., zinc sulphate), agonists of HbF synthesis(e.g., arginine butyrate), and antibiotics. Topical pharmaceuticalinterventions include, for example, antibiotics, antiseptics, growthfactors (e.g., GM-CSF, RGD peptide matrix, Solcoseryl®), steroids (e.g.,cortisone), and pain relievers (e.g., opioids). Non-pharmaceuticalinterventions include, for example, reconstructive surgery, celltherapy, laser therapy, and hyperbaric oxygen.

Ulcers and Sickle Cell Disease

Numerous genes contribute to classical sickle-cell disease (SCD;drepanocytosis; sickle cell anemia). Primarily, SCD is an inheriteddisorder caused by a mutation in the β-globin gene (a mutation of aglutamate to a valine at codon 6). See, e.g., Kassim et al. (2013) AnnuRev Med, 64: 451-466. Sickle-cell anemia refers to the most common formof SCD, with a homozygous mutation in the β^(S) allele (HbSS), affecting60 to 70% of people with SCD.

Because of the mutation in the β-globin gene, abnormal hemoglobinmolecules are produced with a hydrophobic motif that is exposed when itis in a deoxygenated state. See, e.g., Eaton et al. (1990) Adv ProteinChem, 40: 63-279; Steinberg, M H (1999) N Engl J Med 340(13): 1021-1030;and Ballas et al. (1992) Blood, 79(8) 2154-63. Once exposed, the chainsof the separate hemoglobin molecules polymerize, which results in damageto the red blood cell membrane and cellular dehydration. The membranedamage is manifested, in part, by a redistribution of membrane lipidsleading to the expression of phosphatidylserine on the outer leaflet ofthe erythrocyte membrane. See, e.g., (2002) Blood 99(5): 1564-1571.Externalized phosphatidylserine promotes adhesion to both macrophagesand activated endothelial cells, which contributes to vascular (vaso)occlusion. Thus, at low oxygen states, the red cell's hemoglobinprecipitates into long crystals that cause it to elongate,morphologically switching into a “sickled” red blood cell. Both genotypeand the extent and degree of deoxygenation contribute to the severity ofhemoglobin polymerization. It has been demonstrated that the presence offetal hemoglobin proportionally reduces the amount of pathologicalhemoglobin polymers and is protective from vaso-occlusive crises.

Most sickle-cell disease patients experience painful episodes call paincrises. A sickle-cell pain crisis refers to acute sickling-related painthat lasts for at least 1 hour (e.g., at least 1, 2, 3, 4, 5, 6. or 10hours) and optionally requires pain management therapy such as, e.g.,administration of one or more narcotic and/or non-steroidanti-inflammatory agent. A pain crisis typically results in patientadmission to a medical facility for pain management therapy. Acute painin patients with SCD is generally ischemic in nature and can result fromthe occlusion of microvascular beds. Clinical data indicate that somepatients with SCD have from three to ten episodes of pain crisis peryear. In many patients a pain crisis episode will typically be resolvedin about a week. In some cases, severe episodes may persist for severalweeks or even months. SCD pain management often requires administrationof one or more opioid analgesics (e.g. hydromorphone, meperidine, etc.),non-steroidal anti-inflammatory drugs (e.g., ketorolac tromethamine),and corticosteroids. In some embodiments, one or more ActRII antagonistagents of the disclosure, optionally in combination with one or moreagents and/or supportive therapies for treating SCD, may be used totreat or prevent pain crisis in a patient with SCD. In some embodiments,one or more ActRII antagonist agents of the disclosure, optionally incombination with one or more agents and/or supportive therapies fortreating SCD, may be used to reduce the frequency of pain management(e.g., treatment with one or more narcotics, non-steroidanti-inflammatory drugs, and/or corticosteroids) in a SCD patient. Insome embodiments, one or more ActRII antagonist agents of thedisclosure, optionally in combination with one or more agents and/orsupportive therapies for treating SCD, may be used to reduce the dosageamount of one or more pain management agents (e.g., narcotics,non-steroid anti-inflammatory drugs, and/or corticosteroids) in a SCDpatient.

Vaso-occlusive crises are one of the clinical hallmarks of SCD. See,e.g., Rees et al. (2010) Lancet, 376: 2018-2031. Hypoxia, acidosis,inflammatory stress, and endothelial cell activation promote theentrapment of rigid, polymerized sickled erythrocytes and leukocyteswithin small vessels. Sickled red blood cells obstruct capillaries andrestrict blood flow to the organ, leading to ischemia, pain, tissuenecrosis, and damage to various organs. This can cause vascularobstruction, leading to tissue ischemia. Although polymerization andearly membrane damage are initially reversible, repeated sicklingepisodes lead to irreversibly sickled erythrocytes, which can impact avariety of organ systems and lead to death. In some embodiments, one ormore ActRII antagonist agents of the disclosure, optionally incombination with one or more agents and/or supportive therapies fortreating SCD, may be used to treat or prevent vaso-occlusive crisis in aSCD patient. In some embodiments, one or more ActRII antagonist agentsof the disclosure, optionally in combination with one or more agentsand/or supportive therapies for treating SCD, may be used to treat orprevent vaso-occlusion in a SCD patient. In some embodiments, one ormore ActRII antagonist agents of the disclosure, optionally incombination with one or more agents and/or supportive therapies fortreating SCD, may be used to treat or prevent a complication ofvaso-occlusion in a SCD patient. In some embodiments, one or more ActRIIantagonist agents of the disclosure, optionally in combination with oneor more agents and/or supportive therapies for treating SCD, may be usedto treat or prevent vaso-occlusion pain in a SCD patient.

Like vaso-occlusive complications, hemolytic anemia leads to significantmorbidity in SCD patients. See, e.g., Pakbaz et al. (2014) Hematol OncolClin N Am 28: 355-374; Kassim et al. (2013) Annu Rev Med 64: 451-466.Multiple factors contribute to chronic anemia in SCD. As erythrocytesbecome deformed, antibodies are created to exposed antigens, which leadsto increased destruction of erythrocytes, with an average lifespan of 17days instead of 110 to 120 days. The release of hemoglobin duringhemolysis inhibits nitric oxide signaling, leading to endothelial celldysfunction and contributing to a hypercoagulable state. Chronichemolysis contributes to anemia along with an impaired erythrocytecompensatory mechanism caused by hormone and vitamin deficiencies.Progressive renal disease is common in SCD, leading to decreasederythropoietin and thus impaired stimulation erythropoiesis. Folate andiron deficiency are common because of higher demand from erythrocyteproduction and increased urinary iron losses. All of these factorscontribute to chronic anemia in SCD patients. In some embodiments, oneor more ActRII antagonist agents of the disclosure, optionally incombination with one or more agents and/or supportive therapies fortreating SCD, may be used to treat or prevent anemia in a SCD patient.In some embodiments, one or more ActRII antagonist agents of thedisclosure, optionally in combination with one or more agents and/orsupportive therapies for treating sickle cell disease, may be used totreat or prevent a complication of anemia in a SCD patient. In someembodiments, one or more ActRII antagonist agents of the disclosure,optionally in combination with one or more agents and/or supportivetherapies for treating SCD, may be used to treat anemia in a SCDpatient. In some embodiments, one or more ActRII antagonist agents ofthe disclosure, optionally in combination with one or more agents and/orsupportive therapies for treating SCD, may be used to treat acomplication of anemia in a SCD patient. In some embodiments, one ormore ActRII antagonist agents of the disclosure, optionally incombination with one or more agents and/or supportive therapies fortreating SCD, may be used to prevent anemia in a SCD patient. In someembodiments, one or more ActRII antagonist agents of the disclosure,optionally in combination with one or more agents and/or supportivetherapies for treating SCD, may be used to prevent a complication ofanemia in a SCD patient.

Acute anemia, which can be severe and potentially fatal, is associatedwith a 10% to 15% mortality rate, in SCD patients. In general, severeepisodes are precipitated by three main causes: splenic sequestrationcrises, aplastic crises, or hyperhemolytic crises. See, e.g., Ballas etal. (2010) Am J Hematol, 85: 6-13.

Splenic sequestration crises occur as a result of erythrocytevaso-occlusion within the spleen, where a pooling of erythrocytes causesits rapid enlargement. As such, there is a decrease in circulatinghemoglobin (e.g., decreasing by 2 g/dL) and effective circulatingvolume, which may lead to hypovolemic shock. In some embodiments, one ormore ActRII antagonist agents of the disclosure, optionally incombination with one or more agents and/or supportive therapies fortreating SCD, may be used to treat or prevent splenic sequestrationcrises in a SCD patient. In some embodiments, one or more ActRIIantagonist agents of the disclosure, optionally in combination with oneor more agents and/or supportive therapies for treating SCD, may be usedto treat or prevent splenic sequestration of red blood cells in a SCDpatient. In some embodiments, one or more ActRII antagonist agents ofthe disclosure, optionally in combination with one or more agents and/orsupportive therapies for treating SCD, may be used to treat or preventsplenomegaly in a SCD patient. In some embodiments, one or more ActRIIantagonist agents of the disclosure, optionally in combination with oneor more agents and/or supportive therapies for treating SCD, may be usedto treat splenomegaly in a SCD patient. In some embodiments, one or moreActRII antagonist agents of the disclosure, optionally in combinationwith one or more agents and/or supportive therapies for treating SCD,may be used to prevent splenomegaly in a SCD patient.

Aplastic crises arise when erythropoiesis is impaired. Because of theconstant overproduction of erythrocytes, an aplastic crisis can rapidlyresult in severe anemia. Infections, such as parvovirus B19,streptococci, salmonella, and Epstein-Barr virus, are common causes forthe transient arrest of erythropoiesis. Circulating erythrocytes andreticulocytes are both decreased during aplastic crises. In someembodiments, one or more ActRII antagonist agents of the disclosure,optionally in combination with one or more agents and/or supportivetherapies for treating SCD, may be used to treat or prevent aplasticcrises in a SCD patient. In some embodiments, one or more ActRIIantagonist agents of the disclosure, optionally in combination with oneor more agents and/or supportive therapies for treating SCD, may be usedto treat or prevent aplastic anemia in a SCD patient. In someembodiments, one or more ActRII antagonist agents of the disclosure,optionally in combination with one or more agents and/or supportivetherapies for treating SCD, may be used to treat aplastic crises in aSCD patient. In some embodiments, one or more ActRII antagonist agentsof the disclosure, optionally in combination with one or more agentsand/or supportive therapies for treating SCD, may be used to preventaplastic crises in a SCD patient. In some embodiments, one or moreActRII antagonist agents of the disclosure, optionally in combinationwith one or more agents and/or supportive therapies for treating SCD,may be used to treat aplastic anemia in a SCD patient. In someembodiments, one or more ActRII antagonist agents of the disclosure,optionally in combination with one or more agents and/or supportivetherapies for treating SCD, may be used to prevent aplastic anemia in aSCD patient.

Hyperhemolysis occurs when there is a sudden exacerbation of anemia withreticulocytosis, without evidence of splenic sequestration.Hyperhemolysis crises have been documented in patients with multipletransfusions or in patients receiving intravenous immunoglobulintherapy. In some embodiments, one or more ActRII antagonist agents ofthe disclosure, optionally in combination with one or more agents and/orsupportive therapies for treating SCD, may be used to treat or preventhyperhemolytic crises in a SCD patient. In some embodiments, one or moreActRII antagonist agents of the disclosure, optionally in combinationwith one or more agents and/or supportive therapies for treating SCD,may be used to treat or prevent hyperhemolytic anemia in a SCD patient.In some embodiments, one or more ActRII antagonist agents of thedisclosure, optionally in combination with one or more agents and/orsupportive therapies for treating SCD, may be used to treathyperhemolytic crises in a SCD patient. In some embodiments, one or moreActRII antagonist agents of the disclosure, optionally in combinationwith one or more agents and/or supportive therapies for treating SCD,may be used to prevent hyperhemolytic crises in a SCD patient. In someembodiments, one or more ActRII antagonist agents of the disclosure,optionally in combination with one or more agents and/or supportivetherapies for treating SCD, may be used to treat hyperhemolytic anemiain a SCD patient. In some embodiments, one or more ActRII antagonistagents of the disclosure, optionally in combination with one or moreagents and/or supportive therapies for treating SCD, may be used toprevent hyperhemolytic anemia in a SCD patient.

In certain aspects, ActRII antagonist agents of the disclosure,optionally in combination with one or more agents and/or supportivetherapies for treating SCD, may be used to treat or prevent a cardiaccomplication of SCD. Typically, chronic anemia in SCD causes acompensatory increased cardiac output. This, in turn, leads tocardiomegaly and left ventricular hypertrophy with left ventriculardysfunction. See, e.g., Adebayo et al. (2002) Niger J Med, 11: 145-152;Sachdev et al. (2007) J Am Coll Cardiol, 49: 472-279; and Zilberman etal. (2007) Am J Hematol 82: 433-438. Acute myocardial infarction canoccur, even without coronary artery disease, and is thus underdiagnosedin SCD. See, e.g., Pannu et al. (2008) Crit Pathw Cardio, 7: 133-138.Cardiac arrhythmias and congestive heart failure have also been linkedto premature death in SCD patients. See, e.g., Fitzhugh et al. (2010) AmJ Hematol 85: 36-40. In some embodiments, ActRII antagonist agents ofthe disclosure, optionally in combination with one or more agents and/orsupportive therapies for treating SCD, may be used to treat or preventone or more cardiac complications of SCD including, e.g., increasedcardiac output, cardiomegaly, cardiomyopathy, left ventricularhypertrophy, acute myocardial infarction, arrhythmia, and congestiveheart failure. In some embodiments, ActRII antagonist agents of thedisclosure, optionally in combination with one or more agents and/orsupportive therapies for treating SCD, may be used to treat one or morecardiac complications of SCD. In some embodiments, ActRII antagonistagents of the disclosure, optionally in combination with one or moreagents and/or supportive therapies for treating SCD, may be used toprevent one or more cardiac complications of SCD.

In certain aspects, ActRII antagonist agents of the disclosure,optionally in combination with one or more agents and/or supportivetherapies for treating SCD, may be used to treat or prevent a pulmonarycomplication of SCD. SCD frequently results in both acute and chronicpulmonary complications. See, e.g., Rucknagel, D L (2001) Pediatr PatholMOl Med. 20: 137-154; Haynes et al. (1986) Am J Med 80: 833-840. Acutecomplications may include infection, pulmonary emboli from thrombi, bonemarrow infarction, and fat emboli. Pulmonary dysfunction may occurbecause of local pain from rib and sternal infarctions, leading tohypoventilation and atelectasis with hypoxemia. Chronic complicationsinclude sickle cell chronic lung disease and pulmonary hypertension.Acute chest syndrome (ACS) is unique to people with sickle disease andis defined by a new pulmonary infiltrate involving at least 1 completelung segment, chest pain, and temperature above 38.5° C. along withtachypnea, wheeze, or cough. See, e.g., Vichinsky et al. (2000) N Engl JMed, 342: 1855-1865. Development of pulmonary infarction, fat embolism,and infections may all contribute to ACS. Infection is a major cause ofmorbidity and mortality in ACS patients.

Pulmonary hypertension is currently a major cause of morbidity andmortality in SCD. See, e.g., De Castro et al. (2008) Am J Hematol, 83:19-25; Gladwin et al. (2004) N Engl J Med 350: 886-895. Pulmonaryhypertension has been documented in 32% of adults with SCD and isrelated to vaso-occlusive crises and hemolysis. See, e.g., Machado etal. (2010) Chest, 137(6 supple): 30S-38S. Cell-free hemoglobin fromhemolysis is thought to decrease nitric oxide, a pulmonary vasodilator,contributing to vaso-occlusion. See, e.g., Wood et al. (2008) Free RadicBiol Med 44: 1506-1528. In some embodiments, ActRII antagonist agents ofthe disclosure, optionally in combination with one or more agents and/orsupportive therapies for treating SCD, may be used to treat or preventone or more pulmonary complications of SCD including, e.g., fat or bonemarrow emboli, pulmonary edema, sickle-cell lung disease, pulmonaryhypertension, thromboemboli, and Acute chest syndrome. In someembodiments, ActRII antagonist agents of the disclosure, optionally incombination with one or more agents and/or supportive therapies fortreating SCD, may be used to treat one or more pulmonary complicationsof SCD. In some embodiments, ActRII antagonist agents of the disclosure,optionally in combination with one or more agents and/or supportivetherapies for treating SCD, may be used to prevent one or more pulmonarycomplications of SCD.

In certain aspects, ActRII antagonist agents of the disclosure,optionally in combination with one or more agents and/or supportivetherapies for treating SCD, may be used to treat or prevent a hepaticcomplication of SCD. Liver pathology is common in SCD, with hepatomegalybeing observed in ˜90% of autopsy cases. See, e.g., Bauer et al. (1980)Am J med 69: 833-837; Mills et al. (1988) Arch Pathol Lab Med 112:290-294. The effects of sickle cell anemia on the liver includeintrasinusoidal sickling with proximal sinusoidal dilation, Kupffer cellhyperplasia with erythrophagocytosis, and hemosiderosis. Focal necrosis,regenerative nodules, and cirrhosis have also been described inpostmortem examinations. Vaso-occlusion can lead to sinusoidalobstruction and ischemia, resulting in acute sickle hepatic crises.Similar to splenic sequestration, erythrocytes can be sequestered withinthe liver, leading to acute anemia. See, e.g., Lee et al. (1996)Postgrad Med J 72: 487-488. Hepatic sequestration can also lead tointrahepatic cholestasis. See, e.g., Shao et al. (1995) Am JGastroenterol 90: 2045-2050. Ischemia within hepatocytes from sicklingepisodes also leads to ballooning of erythrocytes and intracanalicularcholestasis. Some therapies used for treating SCD also contribute toliver pathology. For example, frequent transfusions lead to increasediron deposition within Kupffer cells (which may lead to iron overload)and increase the risk of infection with blood-borne disease such asviral hepatitis. In some embodiments, ActRII antagonist agents of thedisclosure, optionally in combination with one or more agents and/orsupportive therapies for treating SCD, may be used to treat or preventone or more hepatic complications of SCD including, e.g., hepaticfailure, hepatomegaly, hepatic sequestration, intrahepatic cholestasis,cholelithiasis, and iron overload.

In certain aspects, ActRII antagonist agents of the disclosure,optionally in combination with one or more agents and/or supportivetherapies for treating SCD, may be used to treat or prevent a spleniccomplication of SCD. Splenic sequestration, as previously discussed,occurs as a result of vaso-occlusion of erythrocytes within the spleen.Acute exacerbations result in splenomegaly and occasionally splenicinfarction. More commonly, subclinical splenic sequestration may lead tothe gradual loss of splenic function, leading to functional hypospleniaand asplenia. This, in turn, can lead to an increased susceptibility tosepsis as a result of encapsulated bacteria. In some embodiments, ActRIIantagonist agents of the disclosure, optionally in combination with oneor more agents and/or supportive therapies for treating SCD, may be usedto treat or prevent one or more splenic complications of SCD including,e.g., acute or chronic splenic sequestration, splenomegaly, hyposplenia,asplenia, and splenic infarction. In some embodiments, ActRII antagonistagents of the disclosure, optionally in combination with one or moreagents and/or supportive therapies for treating SCD, may be used totreat one or more splenic complications of SCD. In some embodiments,ActRII antagonist agents of the disclosure, optionally in combinationwith one or more agents and/or supportive therapies for treating SCD,may be used to prevent one or more splenic complications of SCD.

In certain aspects, ActRII antagonist agents of the disclosure,optionally in combination with one or more agents and/or supportivetherapies for treating SCD, may be used to treat or prevent a renalcomplication of SCD. Approximately twelve percent of people with SCDdevelop renal failure. See, e.g., Powars et al. (2205) Medicine 84:363-376; Scheinman, J I (2009) Nat Clin Pract Nephrol 5: 78-88.Vaso-occlusion within the vasa recta capillaries leads tomicrothrombotic infarction and extravasation of erythrocytes into therenal medulla. Blood becomes more viscous in the renal medulla becauseof low oxygen tension, low pH, and high osmolality and, if severe, cancontribute to ischemia, infarction, and papillary necrosis. Repeatedglomerular ischemia leads to glomerulosclerosis. Clinical consequencesof ischemic damage include hematuria, proteinuria, decreasedconcentrating ability, renal tubular acidosis, abnormal proximal tubularfunction, acute and chronic renal failure, and urinary tract infections.In some embodiments, ActRII antagonist agents of the disclosure,optionally in combination with one or more agents and/or supportivetherapies for treating SCD, may be used to treat or prevent one or morerenal complications of SCD including, e.g., acute and/or chronic renalfailure, pyelonephritis, and renal medullary carcinoma. In someembodiments, ActRII antagonist agents of the disclosure, optionally incombination with one or more agents and/or supportive therapies fortreating SCD, may be used to treat one or more renal complications ofSCD. In some embodiments, ActRII antagonist agents of the disclosure,optionally in combination with one or more agents and/or supportivetherapies for treating SCD, may be used to prevent one or more renalcomplications of SCD.

In certain aspects, ActRII antagonist agents of the disclosure,optionally in combination with one or more agents and/or supportivetherapies for treating SCD, may be used to treat or prevent a boneand/or joint complication of SCD. Bone and joint complications are acommon complication in SCD patients. See, e.g., Hemigou et al. (1991) JBone Join Surg Am, 73: 81-92. Pain from the small bones in the hands andfeet, dactylitis, occurs frequently in infants with SCD. Long-termconsequences of vaso-occlusion within bone marrow include infarcts,necrosis, and ultimately degenerative changes. Because of hyposplenia,bacterial infections are more common in SCD. Infarcted bone and bonemarrow are common sites of infection, leading to osteomyelitis andseptic arthritis. Osteonecrosis, or avascular necrosis, occurs afterinfarction with bone and bone marrow. Infarctions are most common withinlong bones such as the humerus, tibia, and femur. Chronic weight bearingcauses stress on abnormal femoral heads and leads to progressive jointdestruction and arthritis. In some embodiments, ActRII antagonist agentsof the disclosure, optionally in combination with one or more agentsand/or supportive therapies for treating SCD, may be used to treat orprevent one or more bone and/or joint complications of SCD including,e.g., infarction, necrosis, osteomyelitis, septic arthritis,osteonecrosis, and osteopenia. In some embodiments, ActRII antagonistagents of the disclosure, optionally in combination with one or moreagents and/or supportive therapies for treating SCD, may be used totreat one or more bone and/or joint complications of SCD. In someembodiments, ActRII antagonist agents of the disclosure, optionally incombination with one or more agents and/or supportive therapies fortreating SCD, may be used to prevent one or more bone and/or jointcomplications complications of SCD.

In certain aspects, ActRII antagonist agents of the disclosure,optionally in combination with one or more agents and/or supportivetherapies for treating SCD, may be used to treat or prevent aneurological complication of SCD. Approximately 25 percent ofindividuals with SCD are affected by neurological injury. See, e.g.,Ohene-Frempong et al. (1998) Blood, 91: 288-294; Verduzco et al. (2009)Blood 114: 5117-5125. The injuries may be acute or chronic.Cerebrovascular accidents are most common in adults, but depend on thegenotype. A person with HbSS has the highest cerebrovascular risk, witha 24 percent likelihood of having a clinical stroke by the age of 45.Ischemic strokes are more common in children under 9 years of age,whereas hemorrhagic strokes are more common in adults. Ischemic strokesoccur because of the occlusion of large intracranial arteries, leadingto ischemia. The ischemia is secondary to occlusion of smaller vesselsby rigid erythrocytes, exacerbated by chronic anemia, a hypercoagulablestate, and flow-related hemodynamic injury to the arterial endothelium,further increasing the likelihood of erythrocyte adhesion. In contrast,hemorrhagic strokes may occur in intraventricular, intraparenchymal, andsubarachnoid spaces. See, e.g., Anson, et al. (1991) J Neurosurg, 75:552-558. Intraventricular hemorrhage may be associated with rupture ofanterior cerebral artery aneurysms or direct extension ofintraparenchymal hemorrhage into the lateral or third ventricle. In someembodiments, ActRII antagonist agents of the disclosure, optionally incombination with one or more agents and/or supportive therapies fortreating SCD, may be used to treat or prevent one or more neurologicalcomplications of SCD including, e.g., aneurysm, ischemic stroke,intraparenchymal hemorrhage, subarachnoid hemorrhage, andintraventricular hemorrhage. In some embodiments, ActRII antagonistagents of the disclosure, optionally in combination with one or moreagents and/or supportive therapies for treating SCD, may be used totreat one or more neurological complications complications of SCD. Insome embodiments, ActRII antagonist agents of the disclosure, optionallyin combination with one or more agents and/or supportive therapies fortreating SCD, may be used to prevent one or more neurologicalcomplications complications of SCD.

In certain aspects, ActRII antagonist agents of the disclosure,optionally in combination with one or more agents and/or supportivetherapies for treating SCD, may be used to treat or prevent anophthalmic complication of SCD. Eye complications in SCD mainly affectthe retina. See, e.g., Downes et al. (2005) Opthalmology, 112:1869-1875; Fadugbagbe et al. (2010) Ann Trop Paediatr 30: 19-26. As aresult of vaso-occlusive crises, peripheral retinal ischemia occurs. Newblood vessels (sea fan formations) form mostly near arteriovenouscrossings and are known as proliferative sickle retinopathy. These newvessels can bleed easily, causing traction retinal detachments andultimately blindness. Non-proliferative retinal changes are also morecommon in SCD. In some embodiments, ActRII antagonist agents of thedisclosure, optionally in combination with one or more agents and/orsupportive therapies for treating SCD, may be used to treat or preventone or more ophthalmic complications of SCD including, e.g., peripheralretinal ischemia, proliferative sickle retinopathy, vitreous hemorrhage,retinal detachment, and non-proliferative retinal changes. In someembodiments, ActRII antagonist agents of the disclosure, optionally incombination with one or more agents and/or supportive therapies fortreating SCD, may be used to treat one or more ophthalmic complicationscomplications of SCD. In some embodiments, ActRII antagonist agents ofthe disclosure, optionally in combination with one or more agents and/orsupportive therapies for treating SCD, may be used to prevent one ormore ophthalmic complications complications of SCD.

In certain aspects, ActRII antagonist agents of the disclosure,optionally in combination with one or more agents and/or supportivetherapies for treating SCD, may be used to treat or prevent a cutaneous(skin) complication of SCD. One of the common cutaneous complications ofSCD is the manifestation of ulcers. See, e.g., Keast et al. (2004)Ostomy Wound Manage., 50(10): 64-70; Trent et al. (2004) Adv Skin WoundCare, 17(8): 410-416; J. R. Eckman (1996) Hematol Oncol Clin North Am.,10(6): 1333-1344; and Chung et al. (1996) Advances in Wound Care, 9(5):46-50. While the mechanism for ulcer development in SCD patients has notbeen fully elucidated, it is believed to be a multifactorial processthat is influenced by various aspects of SCD including, for example,vascular obstruction, increased venous and capillary pressure, abnormalblood rheology, tissue hypoxia, and increased susceptibility tobacterial invasion caused by venous stasis, increased venous pressure,or both. The rate of ulcer healing has been found to be three to 16times slower that the rate in patients with SCD. Ulcers may persist formonths to years and there is a high incidence of reoccurrence in SCDpatients. In some embodiments, ActRII antagonist agents of thedisclosure, optionally in combination with one or more agents and/orsupportive therapies for treating SCD, may be used to treat or preventone or more cutaneous complication of SCD including, e.g., ulcers. Insome embodiments, ActRII antagonist agents of the disclosure, optionallyin combination with one or more agents and/or supportive therapies fortreating SCD, may be used to treat one or more cutaneous complicationscomplications of SCD, e.g., ulcers. In some embodiments, ActRIIantagonist agents of the disclosure, optionally in combination with oneor more agents and/or supportive therapies for treating SCD, may be usedto prevent one or more cutaneous complications complications of SCD,e.g., ulcers.

In certain aspects, ActRII antagonist agents of the disclosure may beadministered to a subject in need thereof in combination with one ormore additional agents (e.g., hydroxyurea, an EPO antagonist, EPO, anopioid analgesic, a non-steroidal anti-inflammatory drug, acorticosteroids, an iron-chelating agent) or supportive therapies (e.g.,red blood cell transfusion) for treating sickle-cell disease or one ormore complications of sickle-cell disease (e.g., cutaneous complicationssuch as cutaneous ulcers).

The mainstay of treatment for the majority of SCD patients issupportive. Current treatment options for patients with sickle celldisease include antibiotics, pain management, intravenous fluids, bloodtransfusion, surgery, and compounds such as hydroxyurea.

Hydroxyurea (e.g. Droxia®) is an approved drug for treating Sickle CellDisease. Hydroxyurea is an S-phase cytotoxic drug and is used forlong-term therapy. It is believed to increase the levels of hemoglobin Fwhich prevents formation of S-polymers and red cell sickling. It is alsobelieved to increase NO production. A multi-center trial of hydroxyureain adults with Sickle Cell Disease showed that hydroxyurea reduced theincidence of painful episodes by nearly half. However, presentlyhydroxyurea is used only in patients who suffer severe complications ofSCD and who are capable of following the daily dosage regimes. Thegeneral belief is that hydroxyurea therapy is effective only if given ina structured environment with a high potential for compliance.Unfortunately, many SCD patients are refractory to hydroxyurea. In someembodiments, the methods of the present disclosure relate to treatingsickle-cell disease in a subject in need thereof by administering acombination of an ActRII antagonist of the disclosure and hydroxyurea.In some embodiments, the methods of the present disclosure relate totreating or preventing one or more complications (e.g., cutaneouscomplications such as cutaneous ulcers) of sickle-cell disease in asubject in need thereof by administering a combination of an ActRIIantagonist of the disclosure and hydroxyurea.

Regular red blood cell transfusions are also a common therapy for SCDpatients. However, several issues make them unsuitable for long-termuse. Although regular transfusions have been shown to prevent stroke,ACS, and vaso-occlusive pain crises, they do not prevent the developmentof silent infarcts or the progression of moyamoya disease, a disorder ofthe cerebral circulation in which certain arteries are constricted andthe compensatory collateral vessels are prone to hemorrhage. See, e.g.,Bishop et al. (2011) Blood Cells, Molecules & Disease, 47: 125-128;DeBaun et al. (2012) Blood, 119: 4787-4596. Furthermore, SCD patientsmay develop iron overload as a consequence of red blood celltransfusion, which is associated with its own morbidity. Regular redblood cell transfusion requires exposure to various donor units of bloodand hence a higher risk of alloimmunization. Difficulties with vascularaccess, availability of and compliance with iron chelation, and the highcost are some of the reasons why regular transfusions are not an optimaloption for universal therapy. Wayne et al. (2000) Blood, 96: 2369-2372.In some embodiments, the methods of the present disclosure relate totreating sickle-cell disease in a subject in need thereof byadministering a combination of an ActRII antagonist of the disclosureand one or more blood cell transfusions. In some embodiments, themethods of the present disclosure relate to treating or preventing oneor more complication of sickle-cell disease in a subject in need thereofby administering a combination of an ActRII antagonist of the disclosureand one or more red blood cell transfusions. In some embodiments,treatment with one or more ActRII antagonists of the disclosure iseffective at decreasing the transfusion requirement in a SCD patient,e.g., reduces the frequency and/or amount of blood transfusion requiredto effectively treat SCD or one or more complications of SCD.

In certain embodiments, one or more ActRII antagonist agents of thedisclosure (e.g., a GDF-ActRII antagonist, an ActRIIA polypeptide, anActRIIB polypeptide, a GDF Trap, etc.) may be used in combination withsupportive therapies for SCD. Such therapies include transfusion witheither red blood cells or whole blood to treat anemia. In SCD patients,normal mechanisms for iron homeostasis are overwhelmed by repeatedtransfusions, eventually leading to toxic and potentially fatalaccumulation of iron in vital tissues such as heart, liver, andendocrine glands. Thus, supportive therapies for SCD patients alsoinclude treatment with one or more iron-chelating molecules to promoteiron excretion in the urine and/or stool and thereby prevent, orreverse, tissue iron overload. Effective iron-chelating agents should beable to selectively bind and neutralize ferric iron, the oxidized formof non-transferrin bound iron which likely accounts for most irontoxicity through catalytic production of hydroxyl radicals and oxidationproducts. See, e.g., Esposito et al. (2003) Blood 102:2670-2677. Theseagents are structurally diverse, but all possess oxygen or nitrogendonor atoms able to form neutralizing octahedral coordination complexeswith individual iron atoms in stoichiometries of 1:1 (hexadentateagents), 2:1 (tridentate), or 3:1 (bidentate). Kalinowski et al. (2005)Pharmacol Rev 57:547-583. In general, effective iron-chelating agentsalso are relatively low molecular weight (e.g., less than 700 daltons),with solubility in both water and lipids to enable access to affectedtissues. Specific examples of iron-chelating molecules includedeferoxamine (also known as desferrioxamine B, desferoxamine B, DFO-B,DFOA, DFB, or Desferal®), a hexadentate agent of bacterial originrequiring daily parenteral administration, and the orally activesynthetic agents deferiprone (also known as Ferriprox®) (bidentate) anddeferasirox (also known as bis-hydroxyphenyl-triazole. ICL670, orExjade®) (tridentate). Combination therapy consisting of same-dayadministration of two iron-chelating agents shows promise in patientsunresponsive to chelation monotherapy and also in overcoming issues ofpoor patient compliance with dereroxamine alone. Cao et al. (2011)Pediatr Rep 3(2):e17; and Galanello et al. (2010) Ann NY Acad Sci1202:79-86.

Ineffective Erythropoiesis and Ulcers

In certain aspects, ActRII antagonist agents of the disclosure,optionally in combination with one or more agents and/or supportivetherapies, may be used to treat or prevent an ineffective erythropoiesisin a subject in need thereof. Originally distinguished from aplasticanemia, hemorrhage, or peripheral hemolysis on the basis of ferrokineticstudies (Ricketts et al., 1978, Clin Nucl Med 3:159-164), ineffectiveerythropoiesis describes a diverse group of anemias in which productionof mature RBCs is less than would be expected given the number oferythroid precursors (erythroblasts) present in the bone marrow (Tannoet al., 2010, Adv Hematol 2010:358283). In such anemias, tissue hypoxiapersists despite elevated erythropoietin levels due to ineffectiveproduction of mature RBCs. A vicious cycle eventually develops in whichelevated erythropoietin levels drive massive expansion of erythroblasts,potentially leading to splenomegaly (spleen enlargement) due toextramedullary erythropoiesis (Aizawa et al, 2003, Am J Hematol74:68-72), erythroblast-induced bone pathology (Di Matteo et al., 2008,J Biol Regul Homeost Agents 22:211-216), and tissue iron overload, evenin the absence of therapeutic RBC transfusions (Pippard et al., 1979,Lancet 2:819-821). Thus, by boosting erythropoietic effectiveness, anActRII antagonist of the disclosure may break the aforementioned cycleand may alleviate not only the underlying anemia but also the associatedcomplications of elevated erythropoietin levels, splenomegaly, bonepathology, and tissue iron overload. ActRII antagonists can treatineffective erythropoiesis, including anemia and elevated EPO levels, aswell as complications such as splenomegaly, erythroblast-induced bonepathology, and iron overload, cutaneous ulcers, and their attendantpathologies. With splenomegaly, such pathologies include thoracic orabdominal pain and reticuloendothelial hyperplasia. Extramedullaryhematopoiesis can occur not only in the spleen but potentially in othertissues in the form of extramedullary hematopoietic pseudotumors(Musallam et al., 2012, Cold Spring Harb Perspect Med 2:a013482). Witherythroblast-induced bone pathology, attendant pathologies include lowbone mineral density, osteoporosis, and bone pain (Haidar i., 2011, Bone48:425-432). With iron overload, attendant pathologies include hepcidinsuppression and hyperabsorption of dietary iron (Musallam et al., 2012,Blood Rev 26(Suppl 1):S16-S19), multiple endocrinopathies and liverfibrosis/cirrhosis (Galanello et al., 2010, Orphanet J Rare Dis 5:11),and iron-overload cardiomyopathy (Lekawanvijit et al., 2009, Can JCardiol 25:213-218).

The most common causes of ineffective erythropoiesis are the thalassemiasyndromes, hereditary hemoglobinopathies in which imbalances in theproduction of intact alpha-and beta-hemoglobin chains lead to increasedapoptosis during erythroblast maturation (Schrier, 2002, Curr OpinHematol 9:123-126). Thalassemias are collectively among the mostfrequent genetic disorders worldwide, with changing epidemiologicpatterns predicted to contribute to a growing public health problem inboth the U.S. and globally (Vichinsky, 2005, Ann NY Acad Sci1054:18-24). Thalassemia syndromes are named according to theirseverity. Thus, a-thalassemias include a-thalassemia minor (also knownas a-thalassemia trait; two affected a-globin genes), hemoglobin Hdisease (three affected a-globin genes), and a-thalassemia major (alsoknown as hydrops fetalis; four affected a-globin genes). β-Thalassemiasinclude β-thalassemia minor (also known as p-thalassemia trait; oneaffected β-globin gene), β-thalassemia intermedia (two affected β-globingenes), hemoglobin E thalassemia (two affected β-globin genes), andβ-thalassemia major (also known as Cooley's anemia; two affectedβ-globin genes resulting in a complete absence of β-globin protein).β-Thalassemia impacts multiple organs, is associated with considerablemorbidity and mortality, and currently requires life-long care. Althoughlife expectancy in patients with β-thalassemia has increased in recentyears due to use of regular blood transfusions in combination with ironchelation, iron overload resulting both from transfusions and fromexcessive gastrointestinal absorption of iron can cause seriouscomplications such as heart disease, thrombosis, hypogonadism,hypothyroidism, diabetes, osteoporosis, and osteopenia (Rund et al,2005, N Engl J Med 353:1135-1146). As demonstrated herein with a mousemodel of β-thalassemia, an ActRIIa antagonist, optionally combined withan EPO receptor activator, can be used to treat thalassemia syndromes.Furthermore, data disclosed herein demonstrates that a GDF Trappolypeptide can be used to promote positive effects on red blood cellparameters (e.g., increased levels of serum hemoglobin) as well as treatcomplications of thalassemia (e.g., cutaneous ulcers) in humanthalassemia patients.

In certain aspects, ActRII antagonist agents of the disclosure,optionally in combination with one or more agents and/or supportivetherapies for treating an ineffective erythropoiesis disorder, such as athalassemia syndrome, may be used to treat or prevent a cutaneous (skin)complication of ineffective erythropoiesis. A common cutaneouscomplication of ineffective erythropoiesis, particularly thalassemia, isthe manifestation of ulcers. While the mechanism for ulcer developmentin thalassemia patients has not been fully elucidated, it is believed tobe a multifactorial process that is influenced by various aspects ofthalassemia including, for example, and tissue hypoxia. In someembodiments, ActRII antagonist agents of the disclosure, optionally incombination with one or more agents and/or supportive therapies fortreating ineffective erythropoiesis (e.g., thalassemia), may be used totreat or prevent one or more cutaneous complication of ineffectiveerythropoiesis (e.g., thalassemia) including, e.g., ulcers. In someembodiments, ActRII antagonist agents of the disclosure, optionally incombination with one or more agents and/or supportive therapies fortreating ineffective erythropoiesis (e.g., thalassemia), may be used totreat one or more cutaneous complications complications of ineffectiveerythropoiesis (e.g., thalassemia) including, e.g., ulcers. In someembodiments, ActRII antagonist agents of the disclosure, optionally incombination with one or more agents and/or supportive therapies fortreating ineffective erythropoiesis (e.g., thalassemia), may be used toprevent one or more cutaneous complications complications of ineffectiveerythropoiesis (e.g., thalassemia) including, e.g., ulcers. In someembodiments, ActRII antagonist agents of the disclosure, optionally incombination with one or more agents and/or supportive therapies fortreating β-thalassemia (e.g., β-thalassemia intermedia), may be used totreat one or more cutaneous complications complications of β-thalassemia(e.g., β-thalassemia intermedia) including, e.g., ulcers. In someembodiments, ActRII antagonist agents of the disclosure, optionally incombination with one or more agents and/or supportive therapies fortreating β-thalassemia (e.g., β-thalassemia intermedia), may be used toprevent one or more cutaneous complications complications ofβ-thalassemia (e.g., β-thalassemia intermedia) including, e.g., ulcers.

Other Anemia Indications

ActRII antagonist of the disclosure, optionally combined with one ormore supportive therapies, can be used for treating disorders ofineffective erythropoiesis besides thalassemia syndromes. Such disordersinclude siderblastic anemia (inherited or acquired); dyserythropoieticanemia (Types I and II); sickle cell anemia; hereditary spherocytosis;pyruvate kinase deficiency; megaloblastic anemias, potentially caused byconditions such as folate deficiency (due to congenital diseases,decreased intake, or increased requirements), cobalamin deficiency (dueto congenital diseases, pernicious anemia, impaired absorption,pancreatic insufficiency, or decreased intake), certain drugs, orunexplained causes (congenital dyserythropoietic anema, refractorymegaloblastic anemia, or erythroleukemia); myelophthisic anemias,including myelofibrosis (myeloid metaplasia) and myelophthisis;congenital erythropoietic porphyria; and lead poisoning.

As shown herein, one or more ActRII antagonist agents of the disclosure(e.g., a GDF-ActRII antagonist, an ActRIIA polypeptide, an ActRIIBpolypeptide, a GDF Trap, etc.), optionally combined with an EPO receptoractivator and one or more additional supportive therapies, may be usedto increase red blood cell, hemoglobin, or reticulocyte levels inhealthy individuals and selected patient populations. Examples ofappropriate patient populations include those with undesirably low redblood cell or hemoglobin levels, such as patients having an anemia,sickle-cell patients, and those that are at risk for developingundesirably low red blood cell or hemoglobin levels, such as thosepatients that are about to undergo major surgery or other proceduresthat may result in substantial blood loss. In some embodiments, apatient with adequate red blood cell levels is treated with one or moreActRII antagonist agents to increase red blood cell levels, and thenblood is drawn and stored for later use in transfusions.

One or more ActRII antagonist agents of the disclosure (e.g., aGDF-ActRII antagonist, an ActRIIA polypeptide, an ActRIIB polypeptide, aGDF Trap, etc.), optionally combined with an EPO receptor activatorand/or other one or more additional supportive therapies, may be used toincrease red blood cell levels, hemoglobin levels, and/or hematocritlevels in a patient having an anemia (e.g., a sickle-cell patient, athalassemia patient, etc.). When observing hemoglobin and/or hematocritlevels in humans, a level of less than normal for the appropriate ageand gender category may be indicative of anemia, although individualvariations are taken into account. For example, a hemoglobin level from10-12.5 g/dl, and typically about 11.0 g/dl is considered to be withinthe normal range in health adults, although, in terms of therapy, alower target level may cause fewer cardiovascular side effects. See,e.g., Jacobs et al. (2000) Nephrol Dial Transplant 15, 15-19.Alternatively, hematocrit levels (percentage of the volume of a bloodsample occupied by the cells) can be used as a measure for anemia.Hematocrit levels for healthy individuals range from about 41-51% foradult males and from 35-45% for adult females. In certain embodiments, apatient may be treated with a dosing regimen intended to restore thepatient to a target level of red blood cells, hemoglobin, and/orhematocrit. As hemoglobin and hematocrit levels vary from person toperson, optimally, the target hemoglobin and/or hematocrit level can beindividualized for each patient.

Anemia is frequently observed in patients having a tissue injury, aninfection, and/or a chronic disease, particularly cancer. In somesubjects, anemia is distinguished by low erythropoietin levels and/or aninadequate response to erythropoietin in the bone marrow. See, e.g.,Adamson, 2008, Harrison's Principles of Internal Medicine, 17th ed.;McGraw Hill, New York, pp 628-634. Potential causes of anemia include,for example, blood-loss, nutritional deficits (e.g. reduced dietaryintake of protein), medication reaction, various problems associatedwith the bone marrow, and many diseases. More particularly, anemia hasbeen associated with a variety of disorders and conditions that include,for example, bone marrow transplantation; solid tumors (e.g., breastcancer, lung cancer, and colon cancer); tumors of the lymphatic system(e.g., chronic lymphocyte leukemia, non-Hodgkin's lymphoma, andHodgkin's lymphoma); tumors of the hematopoietic system (e.g., leukemia,a myclodysplastic syndrome and multiple myeloma); radiation therapy;chemotherapy (e.g., platinum containing regimens); inflammatory andautoimmune diseases, including, but not limited to, rheumatoidarthritis, other inflammatory arthritides, systemic lupus erythematosis(SLE), acute or chronic skin diseases (e.g., psoriasis), inflammatorybowel disease (e.g., Crohn's disease and ulcerative colitis); acute orchronic renal disease or failure, including idiopathic or congenitalconditions; acute or chronic liver disease; acute or chronic bleeding;situations where transfusion of red blood cells is not possible due topatient allo-or auto-antibodies and/or for religious reasons (e.g., someJehovah's Witnesses); infections (e.g., malaria and osteomyelitis);hemoglobinopathies including, for example, sickle cell disease (anemia),a thalassemias; drug use or abuse (e.g., alcohol misuse); pediatricpatients with anemia from any cause to avoid transfusion; and elderlypatients or patients with underlying cardiopulmonary disease with anemiawho cannot receive transfusions due to concerns about circulatoryoverload. See, e.g., Adamson (2008) Harrison's Principles of InternalMedicine, 17th ed.; McGraw Hill, New York, pp 628-634. In someembodiments, one or more ActRII antagonist agents of the disclosure(e.g., a GDF-ActRII antagonist, an ActRIIA polypeptide, an ActRIIBpolypeptide, a GDF Trap, etc.), optionally combined with an EPO receptoractivator, may be used to treat or prevent anemia associated with one ormore of the disorders or conditions disclosed herein. In someembodiments, one or more ActRII antagonist agents of the disclosure(e.g., a GDF-ActRII antagonist, an ActRIIA polypeptide, an ActRIIBpolypeptide, a GDF Trap, etc.), optionally combined with an EPO receptoractivator, may be used to treat anemia associated with one or more ofthe disorders or conditions disclosed herein. In some embodiments, oneor more ActRII antagonist agents of the disclosure (e.g., a GDF-ActRIIantagonist, an ActRIIA polypeptide, an ActRIIB polypeptide, a GDF Trap,etc.), optionally combined with an EPO receptor activator, may be usedto prevent anemia associated with one or more of the disorders orconditions disclosed herein.

Many factors can contribute to cancer-related anemia. Some areassociated with the disease process itself and the generation ofinflammatory cytokines such as interleukin-1, interferon-gamma, andtumor necrosis factor. Bron et al. (2001) Semin Oncol 28(Suppl 8): 1-6.Among its effects, inflammation induces the key iron-regulatory peptidehepcidin, thereby inhibiting iron export from macrophages and generallylimiting iron availability for erythropoiesis. See, e.g., Ganz (2007) JAm Soc Nephrol 18:394-400. Blood loss through various routes can alsocontribute to cancer-related anemia. The prevalence of anemia due tocancer progression varies with cancer type, ranging from 5% in prostatecancer up to 90% in multiple myeloma. Cancer-related anemia has profoundconsequences for patients, including fatigue and reduced quality oflife, reduced treatment efficacy, and increased mortality. In someembodiments, one or more ActRII antagonist agents of the disclosure(e.g., a GDF-ActRII antagonist, an ActRIIA polypeptide, an ActRIIBpolypeptide, a GDF Trap, etc.), optionally combined with an EPO receptoractivator, may be used to treat or prevent a cancer-related anemia. Insome embodiments, one or more ActRII antagonist agents of the disclosure(e.g., a GDF-ActRII antagonist, an ActRIIA polypeptide, an ActRIIBpolypeptide, a GDF Trap, etc.), optionally combined with an EPO receptoractivator, may be used to treat a cancer-related anemia. In someembodiments, one or more ActRII antagonist agents of the disclosure(e.g., a GDF-ActRII antagonist, an ActRIIA polypeptide, an ActRIIBpolypeptide, a GDF Trap, etc.), optionally combined with an EPO receptoractivator, may be used to prevent a cancer-related anemia.

A hypoproliferative anemia can result from primary dysfunction orfailure of the bone marrow. Hypoproliferative anemias include: anemia ofchronic disease, anemia of kidney disease, anemia associated withhypometabolic states, and anemia associated with cancer. In each ofthese types, endogenous erythropoietin levels are inappropriately lowfor the degree of anemia observed. Other hypoproliferative anemiasinclude: early-stage iron-deficient anemia, and anemia caused by damageto the bone marrow. In these types, endogenous erythropoietin levels areappropriately elevated for the degree of anemia observed. Prominentexamples would be myelosuppression caused by cancer and/orchemotherapeutic drugs or cancer radiation therapy. A broad review ofclinical trials found that mild anemia can occur in 100% of patientsafter chemotherapy, while more severe anemia can occur in up to 80% ofsuch patients. See, e.g., Groopman et al. (1999) J Natl Cancer Inst91:1616-1634. Myelosuppressive drugs include, for example: 1) alkylatingagents such as nitrogen mustards (e.g., melphalan) and nitrosoureas(e.g., streptozocin); 2) antimetabolites such as folic acid antagonists(e.g., methotrexate), purine analogs (e.g., thioguanine), and pyrimidineanalogs (e.g., gemcitabine); 3) cytotoxic antibiotics such asanthracyclines (e.g., doxorubicin); 4) kinase inhibitors (e.g.,gefitinib); 5) mitotic inhibitors such as taxanes (e.g., paclitaxel) andvinca alkaloids (e.g., vinorelbine); 6) monoclonal antibodies (e.g.,rituximab); and 7) topoisomerase inhibitors (e.g., topotecan andetoposide). In addition, conditions resulting in a hypometabolic ratecan produce a mild-to-moderate hypoproliferative anemia. Among suchconditions are endocrine deficiency states. For example, anemia canoccur in Addison's disease, hypothyroidism, hyperparathyroidism, ormales who are castrated or treated with estrogen. In some embodiments,one or more ActRII antagonist agents of the disclosure (e.g., aGDF-ActRII antagonist, an ActRIIA polypeptide, an ActRIIB polypeptide, aGDF Trap, etc.), optionally combined with an EPO receptor activator, maybe used to treat or prevent a hyperproliferative anemia.

Chronic kidney disease is sometimes associated with hypoproliferativeanemia, and the degree of the anemia varies in severity with the levelof renal impairment. Such anemia is primarily due to inadequateproduction of erythropoietin and reduced survival of red blood cells.Chronic kidney disease usually proceeds gradually over a period of yearsor decades to end-stage (Stage-5) disease, at which point dialysis orkidney transplantation is required for patient survival. Anemia oftendevelops early in this process and worsens as disease progresses. Theclinical consequences of anemia of kidney disease are well-documentedand include development of left ventricular hypertrophy, impairedcognitive function, reduced quality of life, and altered immunefunction. See, e.g., Levin et al. (1999) Am J Kidney Dis 27:347-354;Nissenson (1992) Am J Kidney Dis 20(Suppl 1):21-24; Revicki et al.(1995) Am J Kidney Dis 25:548-554; Gafter et al., (1994) Kidney Int45:224-231. In some embodiments, one or more ActRII antagonist agents ofthe disclosure (e.g., a GDF-ActRII antagonist, an ActRIIA polypeptide,an ActRIIB polypeptide, a GDF Trap, etc.), optionally combined with anEPO receptor activator, may be used to treat or prevent anemiaassociated with acute or chronic renal disease or failure. In someembodiments, one or more ActRII antagonist agents of the disclosure(e.g., a GDF-ActRII antagonist, an ActRIIA polypeptide, an ActRIIBpolypeptide, a GDF Trap, etc.), optionally combined with an EPO receptoractivator, may be used to treat anemia associated with acute or chronicrenal disease or failure. In some embodiments, one or more ActRIIantagonist agents of the disclosure (e.g., a GDF-ActRII antagonist, anActRIIA polypeptide, an ActRIIB polypeptide, a GDF Trap, etc.),optionally combined with an EPO receptor activator, may be used toprevent anemia associated with acute or chronic renal disease orfailure.

Anemia resulting from acute blood loss of sufficient volume, such asfrom trauma or postpartum hemorrhage, is known as acute post-hemorrhagicanemia. Acute blood loss initially causes hypovolemia without anemiasince there is proportional depletion of RBCs along with other bloodconstituents. However, hypovolemia will rapidly trigger physiologicmechanisms that shift fluid from the extravascular to the vascularcompartment, which results in hemodilution and anemia. If chronic, bloodloss gradually depletes body iron stores and eventually leads to irondeficiency. In some embodiments, one or more ActRII antagonist agents ofthe disclosure (e.g., a GDF-ActRII antagonist, an ActRIIA polypeptide,an ActRIIB polypeptide, a GDF Trap, etc.), may be used to treat anemiaresulting from acute blood loss.

Iron-deficiency anemia is the final stage in a graded progression ofincreasing iron deficiency which includes negative iron balance andiron-deficient erythropoiesis as intermediate stages. Iron deficiencycan result from increased iron demand, decreased iron intake, orincreased iron loss, as exemplified in conditions such as pregnancy,inadequate diet, intestinal malabsorption, acute or chronicinflammation, and acute or chronic blood loss. With mild-to-moderateanemia of this type, the bone marrow remains hypoproliferative, and RBCmorphology is largely normal; however, even mild anemia can result insome microcytic hypochromic RBCs, and the transition to severeiron-deficient anemia is accompanied by hyperproliferation of the bonemarrow and increasingly prevalent microcytic and hypochromic RBCs. See,e.g., Adamson (2008) Harrison's Principles of Internal Medicine, 17thed.; McGraw Hill, New York, pp 628-634. Appropriate therapy foriron-deficiency anemia depends on its cause and severity, with oral ironpreparations, parenteral iron formulations, and RBC transfusion as majorconventional options. In some embodiments, one or more ActRII antagonistagents of the disclosure (e.g., a GDF-ActRII antagonist, an ActRIIApolypeptide, an ActRIIB polypeptide, a GDF Trap, etc.), optionallycombined with an EPO receptor activator, may be used to treat a chroniciron-deficiency.

Myelodysplastic syndrome (MDS) is a diverse collection of hematologicalconditions characterized by ineffective production of myeloid bloodcells and risk of transformation to acute mylogenous leukemia. In MDSpatients, blood stem cells do not mature into healthy red blood cells,white blood cells, or platelets. MDS disorders include, for example,refractory anemia, refractory anemia with ringed sideroblasts,refractory anemia with excess blasts, refractory anemia with excessblasts in transformation, refractory cytopenia with multilineagedysplasia, and myelodysplastic syndrome associated with an isolated 5qchromosome abnormality. As these disorders manifest as irreversibledefects in both quantity and quality of hematopoietic cells, most MDSpatients are afflicted with chronic anemia. Therefore, MDS patientseventually require blood transfusions and/or treatment with growthfactors (e.g., erythropoietin or G-CSF) to increase red blood celllevels. However, many MDS patients develop side-effect due to frequencyof such therapies. For example, patients who receive frequent red bloodcell transfusion can have tissue and organ damage from the buildup ofextra iron. Accordingly, one or more ActRII antagonist agents of thedisclosure (e.g., a GDF-ActRII antagonist, an ActRIIA polypeptide, anActRIIB polypeptide, a GDF Trap, etc.), optionally combined with an EPOreceptor activator, may be used to treat patients having MDS. In certainembodiments, patients suffering from MDS may be treated using one ormore ActRII antagonist agents of the disclosure (e.g., a GDF-ActRIIantagonist, an ActRIIA polypeptide, an ActRIIB polypeptide, a GDF Trap,etc.), optionally in combination with an EPO receptor activator. Inother embodiments, patient suffering from MDS may be treated using acombination of one or more ActRII antagonist agents of the disclosure(e.g., a GDF-ActRII antagonist, an ActRIIA polypeptide, an ActRIIBpolypeptide, a GDF Trap, etc.) and one or more additional therapeuticagents for treating MDS including, for example, thalidomide,lenalidomide, azacitadine, decitabine, erythropoietins, deferoxamine,antithymocyte globulin, and filgrastrim (G-CSF).

As used herein, “in combination with” or “conjoint administration”refers to any form of administration such that the second therapy isstill effective in the body (e.g., the two agents or compounds aresimultaneously effective in the patient, which may include synergisticeffects of the two agents or compounds). Effectiveness may not correlateto measurable concentration of the agent in blood, serum, or plasma. Forexample, the different therapeutic agents or compounds can beadministered either in the same formulation or in separate formulations,either concomitantly or sequentially, and on different schedules. Thus,an individual who receives such treatment can benefit from a combinedeffect of different therapies. One or more GDF11 and/or activin Bantagonist agents (optionally further antagonists of one or more ofGDF8, activin A, activin C, activin E, and BMP6) of the disclosure canbe administered concurrently with, prior to, or subsequent to, one ormore other additional agents or supportive therapies. In general, eachtherapeutic agent will be administered at a dose and/or on a timeschedule determined for that particular agent. The particularcombination to employ in a regimen will take into account compatibilityof the antagonist of the present disclosure with the therapy and/or thedesired therapeutic effect to be achieved.

In certain embodiments, one or more ActRII antagonist agents of thedisclosure (e.g., a GDF-ActRII antagonist, an ActRIIA polypeptide, anActRIIB polypeptide, a GDF Trap, etc.) may be used in combination withhepcidin or a hepcidin agonist for treating sickle-cell disease,particularly sickle-cell disease complications associated with ironoverload. A circulating polypeptide produced mainly in the liver,hepcidin is considered a master regulator of iron metabolism by virtueof its ability to induce the degradation of ferroportin, an iron-exportprotein localized on absorptive enterocytes, hepatocytes, andmacrophages. Broadly speaking, hepcidin reduces availability ofextracellular iron, so hepcidin agonists may be beneficial in thetreatment of sickle-cell disease, particularly sickle-cell diseasecomplications associated with iron overload.

One or more ActRII antagonist agents of the disclosure (e.g., aGDF-ActRII antagonist, an ActRIIA polypeptide, an ActRIIB polypeptide, aGDF Trap, etc.), optionally combined with an EPO receptor activator,would also be appropriate for treating anemias of disordered RBCmaturation, which are characterized in part by undersized (microcytic),oversized (macrocytic), misshapen, or abnormally colored (hypochromic)RBCs.

In certain embodiments, the present disclosure provides methods oftreating or preventing anemia in an individual in need thereof byadministering to the individual a therapeutically effective amount ofone or more ActRII antagonist agents of the disclosure (e.g., aGDF-ActRII antagonist, an ActRIIA polypeptide, an ActRIIB polypeptide, aGDF Trap, etc.) and a EPO receptor activator. In certain embodiments,one or more ActRII antagonist agents of the disclosure (e.g., aGDF-ActRII antagonist, an ActRIIA polypeptide, an ActRIIB polypeptide, aGDF Trap, etc.) may be used in combination with EPO receptor activatorsto reduce the required dose of these activators in patients that aresusceptible to adverse effects of EPO. These methods may be used fortherapeutic and prophylactic treatments of a patient.

One or more ActRII antagonist agents of the disclosure (e.g., aGDF-ActRII antagonist, an ActRIIA polypeptide, an ActRIIB polypeptide, aGDF Trap, etc.) of the disclosure may be used in combination with EPOreceptor activators to achieve an increase in red blood cells,particularly at lower dose ranges. This may be beneficial in reducingthe known off-target effects and risks associated with high doses of EPOreceptor activators. The primary adverse effects of EPO include, forexample, an excessive increase in the hematocrit or hemoglobin levelsand polycythemia. Elevated hematocrit levels can lead to hypertension(more particularly aggravation of hypertension) and vascular thrombosis.Other adverse effects of EPO which have been reported, some of whichrelate to hypertension, are headaches, influenza-like syndrome,obstruction of shunts, myocardial infarctions and cerebral convulsionsdue to thrombosis, hypertensive encephalopathy, and red cell blood cellaplasia. See, e.g., Singibarti (1994) J. Clin Investig 72(suppl 6),S36-S43; Horl et al. (2000) Nephrol Dial Transplant 15(suppl 4), 51-56;Delanty et al. (1997) Neurology 49, 686-689; and Bunn (2002) N Engl JMed 346(7), 522-523).

Provided that antagonists of the present disclosure act by a differentmechanism that EPO, these antagonists may be useful for increasing redblood cell and hemoglobin levels in patients that do not respond well toEPO. For example, an ActRII antagonist of the present disclosure may bebeneficial for a patient in which administration of a normal toincreased (>300 IU/kg/week) dose of EPO does not result in the increaseof hemoglobin level up to the target level. Patients with an inadequateEPO response are found for all types of anemia, but higher numbers ofnon-responders have been observed particularly frequently in patientswith cancers and patients with end-stage renal disease. An inadequateresponse to EPO can be either constitutive (observed upon the firsttreatment with EPO) or acquired (observed upon repeated treatment withEPO).

In certain embodiments, the present disclosure provides methods formanaging a patient that has been treated with, or is a candidate to betreated with, one or more one or more ActRII antagonist agents of thedisclosure (e.g., a GDF-ActRII antagonist, an ActRIIA polypeptide, anActRIIB polypeptide, a GDF Trap, etc.) by measuring one or morehematologic parameters in the patient. The hematologic parameters may beused to evaluate appropriate dosing for a patient who is a candidate tobe treated with the antagonist of the present disclosure to monitor thehematologic parameters during treatment, to evaluate whether to adjustthe dosage during treatment with one or more antagonist of thedisclosure, and/or to evaluate an appropriate maintenance dose of one ormore antagonists of the disclosure. If one or more of the hematologicparameters are outside the normal level, dosing with one or more ActRIIantagonist agents of the disclosure (e.g., a GDF-ActRII antagonist, anActRIIA polypeptide, an ActRIIB polypeptide, a GDF Trap, etc.) may bereduced, delayed or terminated.

Hematologic parameters that may be measured in accordance with themethods provided herein include, for example, red blood cell levels,blood pressure, iron stores, and other agents found in bodily fluidsthat correlate with increased red blood cell levels, using artrecognized methods. Such parameters may be determined using a bloodsample from a patient. Increases in red blood cell levels, hemoglobinlevels, and/or hematocrit levels may cause increases in blood pressure.

In one embodiment, if one or more hematologic parameters are outside thenormal range or on the high side of normal in a patient who is acandidate to be treated with one or more ActRII antagonist agents of thedisclosure (e.g., a GDF-ActRII antagonist, an ActRIIA polypeptide, anActRIIB polypeptide, a GDF Trap, etc.), then onset of administration ofthe one or more antagonists of the disclosure may be delayed until thehematologic parameters have returned to a normal or acceptable leveleither naturally or via therapeutic intervention. For example, if acandidate patient is hypertensive or pre-hypertensive, then the patientmay be treated with a blood pressure lowering agent in order to reducethe patient's blood pressure. Any blood pressure lowering agentappropriate for the individual patient's condition may be usedincluding, for example, diuretics, adrenergic inhibitors (includingalpha blockers and beta blockers), vasodilators, calcium channelblockers, angiotensin-converting enzyme (ACE) inhibitors, or angiotensin11 receptor blockers. Blood pressure may alternatively be treated usinga diet and exercise regimen. Similarly, if a candidate patient has ironstores that are lower than normal, or on the low side of normal, thenthe patient may be treated with an appropriate regimen of diet and/oriron supplements until the patient's iron stores have returned to anormal or acceptable level. For patients having higher than normal redblood cell levels and/or hemoglobin levels, then administration of theone or more antagonists of the disclosure may be delayed until thelevels have returned to a normal or acceptable level.

In certain embodiments, if one or more hematologic parameters areoutside the normal range or on the high side of normal in a patient whois a candidate to be treated with one or more ActRII antagonist agentsof the disclosure (e.g., a GDF-ActRII antagonist, an ActRIIApolypeptide, an ActRIIB polypeptide, a GDF Trap, etc.), then the onsetof administration may not be delayed. However, the dosage amount orfrequency of dosing of the one or more antagonists of the disclosure maybe set at an amount that would reduce the risk of an unacceptableincrease in the hematologic parameters arising upon administration ofthe one or more antagonists of the disclosure. Alternatively, atherapeutic regimen may be developed for the patient that combines oneor more ActRII antagonist agents of the disclosure (e.g., a GDF-ActRIIantagonist, an ActRIIA polypeptide, an ActRIIB polypeptide, a GDF Trap,etc.) with a therapeutic agent that addresses the undesirable level ofthe hematologic parameter. For example, if the patient has elevatedblood pressure, then a therapeutic regimen may be designed involvingadministration of one or more ActRII antagonist agents of the disclosure(e.g., a GDF-ActRII antagonist, an ActRIIA polypeptide, an ActRIIBpolypeptide, a GDF Trap, etc.) and a blood pressure lowering agent. Fora patient having lower than desired iron stores, a therapeutic regimenmay be developed involving one or more ActRII antagonist agents of thedisclosure (e.g., a GDF-ActRII antagonist, an ActRIIA polypeptide, anActRIIB polypeptide, a GDF Trap, etc.) and iron supplementation.

In one embodiment, baseline parameter(s) for one or more hematologicparameters may be established for a patient who is a candidate to betreated with one or more ActRII antagonist agents of the disclosure(e.g., a GDF-ActRII antagonist, an ActRIIA polypeptide, an ActRIIBpolypeptide, a GDF Trap, etc.) and an appropriate dosing regimenestablished for that patient based on the baseline value(s).Alternatively, established baseline parameters based on a patient'smedical history could be used to inform an appropriate antagonist dosingregimen for a patient. For example, if a healthy patient has anestablished baseline blood pressure reading that is above the definednormal range it may not be necessary to bring the patient's bloodpressure into the range that is considered normal for the generalpopulation prior to treatment with the one or more antagonist of thedisclosure. A patient's baseline values for one or more hematologicparameters prior to treatment with one or more ActRII antagonist agentsof the disclosure (e.g., a GDF-ActRII antagonist, an ActRIIApolypeptide, an ActRIIB polypeptide, a GDF Trap, etc.) may also be usedas the relevant comparative values for monitoring any changes to thehematologic parameters during treatment with the one or more antagonistsof the disclosure.

In certain embodiments, one or more hematologic parameters are measuredin patients who are being treated with one or more ActRII antagonistagents of the disclosure (e.g., a GDF-ActRII antagonist, an ActRIIApolypeptide, an ActRIIB polypeptide, a GDF Trap, etc.). The hematologicparameters may be used to monitor the patient during treatment andpermit adjustment or termination of the dosing with the one or moreantagonist of the disclosure or additional dosing with anothertherapeutic agent. For example, if administration of one or more ActRIIantagonist agents of the disclosure (e.g., a GDF-ActRII antagonist, anActRIIA polypeptide, an ActRIIB polypeptide, a GDF Trap, etc.) resultsin an increase in blood pressure, red blood cell level, or hemoglobinlevel, or a reduction in iron stores, then the dose of the one or moreantagonist of the disclosure may be reduced in amount or frequency inorder to decrease the effects of the one or more antagonist of thedisclosure on the one or more hematologic parameters. If administrationof one or more ActRII antagonist agents of the disclosure (e.g., aGDF-ActRII antagonist, an ActRIIA polypeptide, an ActRIIB polypeptide, aGDF Trap, etc.) results in a change in one or more hematologicparameters that is adverse to the patient, then the dosing of the one ormore antagonist of the disclosure may be terminated either temporarily,until the hematologic parameter(s) return to an acceptable level, orpermanently. Similarly, if one or more hematologic parameters are notbrought within an acceptable range after reducing the dose or frequencyof administration of the one or more antagonist of the disclosure, thenthe dosing may be terminated. As an alternative, or in addition to,reducing or terminating the dosing with the one or more antagonist ofthe disclosure, the patient may be dosed with an additional therapeuticagent that addresses the undesirable level in the hematologicparameter(s), such as, for example, a blood pressure lowering agent oran iron supplement. For example, if a patient being treated with one ormore ActRII antagonist agents of the disclosure (e.g., a GDF-ActRIIantagonist, an ActRIIA polypeptide, an ActRIIB polypeptide, a GDF Trap,etc.)e has elevated blood pressure, then dosing with the one or moreantagonist of the disclosure may continue at the same level and a bloodpressure lowering agent is added to the treatment regimen, dosing withthe one or more antagonist of the disclosure may be reduce (e.g., inamount and/or frequency) and a blood pressure lowering agent is added tothe treatment regimen, or dosing with the one or more antagonist of thedisclosure may be terminated and the patient may be treated with a bloodpressure lowering agent.

6. Pharmaceutical Compositions

In certain aspects, one or more ActRII antagonist agents of thedisclosure (e.g., a GDF-ActRII antagonist, an ActRIIA polypeptide, anActRIIB polypeptide, a GDF Trap, etc.) can be administered alone or as acomponent of a pharmaceutical formulation (also referred to as atherapeutic composition or pharmaceutical composition). A pharmaceuticalformation refers to a preparation which is in such form as to permit thebiological activity of an active ingredient (e.g., an agent of thepresent disclosure) contained therein to be effective and which containsno additional components which are unacceptably toxic to a subject towhich the formulation would be administered. The subject ActRIIantagonist agents may be formulated for administration in any convenientway for use in human or veterinary medicine. For example, one or moreActRII antagonist agents of the present disclosure may be formulatedwith a pharmaceutically acceptable carrier. A pharmaceuticallyacceptable carrier refers to an ingredient in a pharmaceuticalformulation, other than an active ingredient, which is generallynontoxic to a subject. A pharmaceutically acceptable carrier includes,but is not limited to, a buffer, excipient, stabilizer, and/orpreservative. In general, pharmaceutical formulations for use in thepresent disclosure are in a pyrogen-free, physiologically-acceptableform when administered to a subject. Therapeutically useful agents otherthan those described herein, which may optionally be included in theformulation as described above, may be administered in combination withthe subject ActRII antagonist agents in the methods of the presentdisclosure.

In certain aspects, the disclosure provides a method of using apharmaceutical composition comprising an ActRII antagonist and apharmaceutically acceptable carrier to treat or prevent treat or preventan anemia in a subject in need thereof and/or treat or prevent one ormore complication of anemia including, for example, cutaneous ulcers. Insome embodiments, the disclosure provides methods of using apharmaceutical composition comprising an ActRII antagonist, orcombination of ActRII antagonists, and a pharmaceutically acceptablecarrier to treat an anemia in a subject in need thereof and/or treat oneor more complications of anemia including, for example, cutaneous ulcersin a subject having anemia. In some embodiments, the disclosure providesmethods of using a pharmaceutical composition comprising an ActRIIantagonist, or combination of ActRII antagonists, and a pharmaceuticallyacceptable carrier to prevent an anemia in a subject in need thereofand/or prevent one or more complications of anemia including, forexample, cutaneous ulcers in a subject having anemia. In some of theforegoing embodiments, the pharmaceutical compositions comprising anActRII antagonist, or combination of ActRII antagonists, and apharmaceutically acceptable carrier of the present disclosure are usedto treat an ulcer (e.g., a cutaneous ulcer) in a subject (e.g., patient)having anemia (e.g., hemolytic anemia, hemoglobinopathy anemia, athalassemia syndrome (e.g., β-thalassemia syndrome, fi-thalassemiaintermedia, etc.), sickle-cell disease, etc.). In some of the foregoingembodiments, the pharmaceutical compositions comprising an ActRIIantagonist, or combination of ActRII antagonists, and a pharmaceuticallyacceptable carrier of the present disclosure are used to prevent anulcer (e.g., a cutaneous ulcer) in a subject (e.g., patient) havinganemia (e.g., hemolytic anemia, hemoglobinopathy anemia, a thalassemiasyndrome (e.g., β-thalassemia syndrome, β-thalassemia intermedia, etc.),sickle-cell disease, etc.). In some embodiments, the subject havinganemia has sickle cell disease. In some embodiments, the subject havinganemia has a thalassemia syndrome (e.g., β-thalassemia syndrome,β-thalassemia intermedia, etc.). In some embodiments, the subject havinganemia has a cutaneous ulcer. In some embodiments, the cutaneous ulceris a skin ulcer. In some embodiments, the ulcer occurs on legs orankles.

In certain embodiments, the ActRII antagonist agents or thepharmaceutical compositions of the disclosure will be administeredparenterally [e.g., by intravenous (I.V.) injection, intraarterialinjection, intraosseous injection, intramuscular injection, intrathecalinjection, subcutaneous injection, or intradermal injection].Pharmaceutical compositions suitable for parenteral administration maycomprise one or more ActRII antagonist agents of the disclosure incombination with one or more pharmaceutically acceptable sterileisotonic aqueous or nonaqueous solutions, dispersions, suspensions oremulsions, or sterile powders which may be reconstituted into sterileinjectable solutions or dispersions just prior to use. Injectablesolutions or dispersions may contain antioxidants, buffers,bacteriostats, suspending agents, thickening agents, or solutes whichrender the formulation isotonic with the blood of the intendedrecipient. Examples of suitable aqueous and nonaqueous carriers whichmay be employed in the pharmaceutical formulations of the presentdisclosure include water, ethanol, polyols (e.g., glycerol, propyleneglycol, polyethylene glycol, etc.), vegetable oils (e.g., olive oil),injectable organic esters (e.g., ethyl oleate), and suitable mixturesthereof. Proper fluidity can be maintained, for example, by the use ofcoating materials (e.g., lecithin), by the maintenance of the requiredparticle size in the case of dispersions, and by the use of surfactants.In certain embodiments, the ActRII antagonist agents or thepharmaceutical compositions of the disclosure will be administeredsubcutaneously (e.g., subcutaneous injection). In certain embodiments,the ActRII antagonist agents or the pharmaceutical compositions of thedisclosure will be administered topically.

In some embodiments, a therapeutic method of the present disclosureincludes administering the pharmaceutical composition of the presentdisclosure systemically, or locally, from an implant or device. Further,the pharmaceutical composition of the present disclosure may beencapsulated or injected in a form for delivery to a target tissue site(e.g., bone marrow or muscle). In certain embodiments, thepharmaceutical compositions of the present disclosure may include amatrix capable of delivering one or more of the agents of the presentdisclosure to a target tissue site (e.g., bone marrow or muscle),providing a structure for the developing tissue and optimally capable ofbeing resorbed into the body. For example, the matrix may provide slowrelease of one or more agents of the present disclosure. Such matricesmay be formed of materials presently in use for other implanted medicalapplications.

The choice of matrix material may be based on one or more of:biocompatibility, biodegradability, mechanical properties, cosmeticappearance, and interface properties. The particular application of thesubject compositions will define the appropriate formulation. Potentialmatrices for the compositions may be biodegradable and chemicallydefined calcium sulfate, tricalciumphosphate, hydroxyapatite, polylacticacid, and polyanhydrides. Other potential materials are biodegradableand biologically well-defined including, for example, bone or dermalcollagen. Further matrices are comprised of pure proteins orextracellular matrix components. Other potential matrices arenon-biodegradable and chemically defined including, for example,sintered hydroxyapatite, bioglass, aluminates, or other ceramics.Matrices may be comprised of combinations of any of the above mentionedtypes of material including, for example, polylactic acid andhydroxyapatite or collagen and tricalciumphosphate. The bioceramics maybe altered in composition (e.g., calcium-aluminate-phosphate) andprocessing to alter one or more of pore size, particle size, particleshape, and biodegradability.

In certain embodiments, the pharmaceutical compositions of the presentdisclosure can be administered topically. “Topical application” or“topically” means contact of the pharmaceutical composition with bodysurfaces including, for example, the skin, wound sites, ulcer sites, andmucous membranes. The topical pharmaceutical compositions can havevarious application forms and typically comprise a drug-containinglayer, which is adapted to be placed near to or in direct contact withthe tissue upon topically administering the composition. Pharmaceuticalcompositions suitable for topical administration may comprise one ormore ActRII antagonist agents of the disclosure (e.g., a GDF-ActRIIantagonist, an ActRIIA polypeptide, an ActRIIB polypeptide, a GDF Trap,etc.) formulated as a liquid, a gel, a cream, a lotion, an ointment, afoam, a paste, a putty, a semi-solid, or a solid. Pharmaceuticalcompositions in the liquid, gel, cream, lotion, ointment, foam, paste,or putty form can be applied by spreading, spraying, smearing, dabbingor rolling the composition on the target tissue. The pharmaceuticalcompositions also may be impregnated into sterile dressings, transdermalpatches, plasters, and bandages. Pharmaceutical compositions of theputty, semi-solid or solid forms may be deformable. They may be elasticor non-elastic (e.g., flexible or rigid). In certain aspects, thepharmaceutical composition forms part of a composite and can includefibers, particulates, or multiple layers with the same or differentcompositions.

Topical compositions in the liquid form may include pharmaceuticallyacceptable solutions, emulsions, microemulsions, and suspensions. Inaddition to the active ingredient(s), the liquid dosage form may containan inert diluent commonly used in the art including, for example, wateror other solvent, a solubilizing agent and/or emulsifier [e.g., ethylalcohol, isopropyl alcohol, ethyl carbonate, ethyl acetate, benzylalcohol, benzyl benzoate, propylene glycol, or 1,3-butylene glycol, anoil (e.g., cottonseed, groundnut, corn, germ, olive, castor, and sesameoil), glycerol, tetrahydrofuryl alcohol, a polyethylene glycol, a fattyacid ester of sorbitan, and mixtures thereof].

Topical gel, cream, lotion, ointment, semi-solid or solid compositionsmay include one or more thickening agents, such as a polysaccharide,synthetic polymer or protein-based polymer. In one embodiment of theinvention, the gelling agent herein is one that is suitably nontoxic andgives the desired viscosity. The thickening agents may include polymers,copolymers, and monomers of: vinylpyrrolidones, methacrylamides,acrylamides N-vinylimidazoles, carboxy vinyls, vinyl esters, vinylethers, silicones, polyethyleneoxides, polyethyleneglycols,vinylalcohols, sodium acrylates, acrylates, maleic acids,NN-dimethylacrylamides, diacetone acrylamides, acrylamides, acryloylmorpholine, pluronic, collagens, polyacrylamides, polyacrylates,polyvinyl alcohols, polyvinylenes, polyvinyl silicates, polyacrylatessubstituted with a sugar (e.g., sucrose, glucose, glucosamines,galactose, trehalose, mannose, or lactose), acylamidopropane sulfonicacids, tetramethoxyorthosilicates, methyltrimethoxyorthosilicates,tetraalkoxyorthosilicates, trialkoxyorthosilicates, glycols, propyleneglycol, glycerine, polysaccharides, alginates, dextrans, cyclodextrin,celluloses, modified celluloses, oxidized celluloses, chitosans,chitins, guars, carrageenans, hyaluronic acids, inulin, starches,modified starches, agarose, methylcelluloses, plant gums, hylaronans,hydrogels, gelatins, glycosaminoglycans, carboxymethyl celluloses,hydroxyethyl celluloses, hydroxy propyl methyl celluloses, pectins,low-methoxy pectins, cross-linked dextrans, starch-acrylonitrile graftcopolymers, starch sodium polyacrylate, hydroxyethyl methacrylates,hydroxyl ethyl acrylates, polyvinylene, polyethylvinylethers, polymethylmethacrylates, polystyrenes, polyurethanes, polyalkanoates, polylacticacids, polylactates, poly(3-hydroxybutyrate), sulfonated hydrogels, AMPS(2-acrylamido-2-methyl-1-propanesulfonic acid), SEM(sulfoethylmethacrylate), SPM (sulfopropyl methacrylate), SPA(sulfopropyl acrylate),N,N-dimethyl-N-methacryloxyethyl-N-(3-sulfopropyl)ammonium betaine,methacryllic acid amidopropyl-dimethyl ammonium sulfobetaine, SPI(itaconic acid-bis(1-propyl sulfonizacid-3) ester di-potassium salt),itaconic acids. AMBC (3-acrylamido-3-methylbutanoic acid),beta-carboxyethyl acrylate (acrylic acid dimers), and maleicanhydride-methylvinyl ether polymers, derivatives thereof, saltsthereof, acids thereof, and combinations thereof. In certainembodiments, pharmaceutical compositions of present disclosure can beadministered orally, for example, in the form of capsules, cachets,pills, tablets, lozenges (using a flavored basis such as sucrose andacacia or tragacanth), powders, granules, a solution or a suspension inan aqueous or non-aqueous liquid, an oil-in-water or water-in-oil liquidemulsion, or an elixir or syrup, or pastille (using an inert base, suchas gelatin and glycerin, or sucrose and acacia), and/or a mouth wash,each containing a predetermined amount of an ActRII antagonist agent ofthe present disclosure and optionally one or more other activeingredients. An ActRII antagonist agent of the present disclosure andoptionally one or more other active ingredients may also be administeredas a bolus, electuary, or paste.

In solid dosage forms for oral administration (e.g., capsules, tablets,pills, dragees, powders, and granules), one or more ActRII antagonistagents of the present disclosure may be mixed with one or morepharmaceutically acceptable carriers including, for example, sodiumcitrate, dicalcium phosphate, a filler or extender (e.g., a starch,lactose, sucrose, glucose, mannitol, and silicic acid), a binder (e.g.carboxymethylcellulose, an alginate, gelatin, polyvinyl pyrrolidone,sucrose, and acacia), a humectant (e.g., glycerol), a disintegratingagent (e.g., agar-agar, calcium carbonate, potato or tapioca starch,alginic acid, a silicate, and sodium carbonate), a solution retardingagent (e.g. paraffin), an absorption accelerator (e.g. a quaternaryammonium compound), a wetting agent (e.g., cetyl alcohol and glycerolmonostearate), an absorbent (e.g., kaolin and bentonite clay), alubricant (e.g., a talc, calcium stearate, magnesium stearate, solidpolyethylene glycols, sodium lauryl sulfate), a coloring agent, andmixtures thereof. In the case of capsules, tablets, and pills, thepharmaceutical formulation (composition) may also comprise a bufferingagent. Solid compositions of a similar type may also be employed asfillers in soft and hard-filled gelatin capsules using one or moreexcipients including, e.g., lactose or a milk sugar as well as a highmolecular-weight polyethylene glycol.

Liquid dosage forms for oral administration of the pharmaceuticalcomposition of the disclosure may include pharmaceutically acceptableemulsions, microemulsions, solutions, suspensions, syrups, and elixirs.In addition to the active ingredient(s), the liquid dosage form maycontain an inert diluent commonly used in the art including, forexample, water or other solvent, a solubilizing agent and/or emulsifier[e.g., ethyl alcohol, isopropyl alcohol, ethyl carbonate, ethyl acetate,benzyl alcohol, benzyl benzoate, propylene glycol, or 1,3-butyleneglycol, an oil (e.g., cottonseed, groundnut, corn, germ, olive, castor,and sesame oil), glycerol, tetrahydrofuryl alcohol, a polyethyleneglycol, a fatty acid ester of sorbitan, and mixtures thereof]. Besidesinert diluents, the oral formulation can also include an adjuvantincluding, for example, a wetting agent, an emulsifying and suspendingagent, a sweetening agent, a flavoring agent, a coloring agent, aperfuming agent, a preservative agent, and combinations thereof.

Suspensions, in addition to the active ActRII antagonist agents, maycontain suspending agents including, for example, an ethoxylatedisostearyl alcohol, polyoxyethylene sorbitol, a sorbitan ester,microcrystalline cellulose, aluminum metahydroxide, bentonite,agar-agar, tragacanth, and combinations thereof.

Prevention of the action and/or growth of microorganisms may be ensuredby the inclusion of various antibacterial and antifungal agentsincluding, for example, paraben, chlorobutanol, and phenol sorbic acid.

In certain embodiments, it may be desirable to include an isotonic agentincluding, for example, a sugar or sodium chloride into thepharmaceutical compositions. In addition, prolonged absorption of aninjectable pharmaceutical form may be brought about by the inclusion ofan agent that delay absorption including, for example, aluminummonostearate and gelatin.

It is understood that the dosage regimen will be determined by theattending physician considering various factors which modify the actionof the one or more of the agents of the present disclosure. The variousfactors include, but are not limited to, the patient's red blood cellcount, hemoglobin level, the desired target red blood cell count, thepatient's age, the patient's sex, the patient's diet, the severity ofany disease that may be contributing to a depressed red blood celllevel, the time of administration, and other clinical factors. Theaddition of other known active agents to the final composition may alsoaffect the dosage. Progress can be monitored by periodic assessment ofone or more of red blood cell levels, hemoglobin levels, reticulocytelevels, and other indicators of the hematopoietic process.

In certain embodiments, the present disclosure also provides genetherapy for the in vivo production of one or more of the ActRIIantagonist agents of the present disclosure. Such therapy would achieveits therapeutic effect by introduction of the agent sequences into cellsor tissues having one or more of the disorders as listed above. Deliveryof the agent sequences can be achieved, for example, by using arecombinant expression vector such as a chimeric virus or a colloidaldispersion system. In some embodiments, therapeutic delivery of one ormore of agent sequences of the disclosure is the use of targetedliposomes.

Various viral vectors which can be utilized for gene therapy as taughtherein include adenovirus, herpes virus, vaccinia, or an RNA virus(e.g., a retrovirus). The retroviral vector may be a derivative of amurine or avian retrovirus. Examples of retroviral vectors in which asingle foreign gene can be inserted include, but are not limited to:Moloney murine leukemia virus (MoMuLV), Harvey murine sarcoma virus(HaMuSV), murine mammary tumor virus (MuMTV), and Rous Sarcoma Virus(RSV). A number of additional retroviral vectors can incorporatemultiple genes. All of these vectors can transfer or incorporate a genefor a selectable marker so that transduced cells can be identified andgenerated. Retroviral vectors can be made target-specific by attaching,for example, a sugar, a glycolipid, or a protein. In some embodiments,targeting is accomplished by using an antibody. Those of skill in theart will recognize that specific polynucleotide sequences can beinserted into the retroviral genome or attached to a viral envelope toallow target specific delivery of the retroviral vector containing oneor more of the agents of the present disclosure.

Alternatively, tissue culture cells can be directly transfected withplasmids encoding the retroviral structural genes (gag, pol, and env),by conventional calcium phosphate transfection. These cells are thentransfected with the vector plasmid containing the genes of interest.The resulting cells release the retroviral vector into the culturemedium.

Another targeted delivery system for one or more of the agents of thepresent disclosure is a colloidal dispersion system. Colloidaldispersion systems include, for example, macromolecule complexes,nanocapsules, microspheres, beads, and lipid-based systems includingoil-in-water emulsions, micelles, mixed micelles, and liposomes. Incertain embodiments, the colloidal system of this disclosure is aliposome. Liposomes are artificial membrane vesicles which are useful asdelivery vehicles in vitro and in vivo. RNA, DNA, and intact virions canbe encapsulated within the aqueous interior and be delivered to cells ina biologically active form. See, e.g., Fraley, et al. (1981) TrendsBiochem. Sci., 6:77. Methods for efficient gene transfer using aliposome vehicle are known in the art. See, e.g., Mannino, et al. (1988)Biotechniques, 6:682, 1988.

The composition of the liposome is usually a combination ofphospholipids, which may include a steroid (e.g. cholesterol). Thephysical characteristics of liposomes depend on pH, ionic strength, andthe presence of divalent cations. Other phospholipids or other lipidsmay also be used including, for example a phosphatidyl compound (e.g.,phosphatidylglycerol, phosphatidylcholine, phosphatidylserine,phosphatidylethanolamine, a sphingolipid, a cerebroside, and aganglioside), egg phosphatidylcholine, dipalmitoylphosphatidylcholine,and distearoylphosphatidylcholine. The targeting of liposomes is alsopossible based on, for example, organ-specificity, cell-specificity, andorganelle-specificity and is known in the art.

EXEMPLIFICATION

The invention now being generally described, it will be more readilyunderstood by reference to the following examples, which are includedmerely for purposes of illustration of certain embodiments andembodiments of the present invention, and are not intended to limit theinvention.

Example 1 ActRIIa-Fc Fusion Proteins

Applicant constructed a soluble ActRIIA fusion protein that has theextracellular domain of human ActRIIa fused to a human or mouse Fcdomain with a minimal linker in between. The constructs are referred toas ActRIIA-hFc and ActRIIA-mFc, respectively.

ActRIIA-hFc is shown below as purified from CHO cell lines (Fc portionunderlined) (SEQ ID NO:22):

ILGRSETQECLFFNANWEKDRTNQTGVEPCYGDKDKRRHCFATWKNISGSIEIVKQGCWLDDINCYDRTDCVEKKDSPEVYFCCCEGNMCNEKFSYFPEMEVTQPTSNPVTPKPPTGGGTHTCPPCPAPELLGGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSHEDPEVKFNWYVDGVEVHNAKTKPREEQYNSTYRVVSVLTVLHQDWLNGKEYKCKVSNKALPVPIEKTISKAKGQPREPQVYTLPPSREEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQGNVFSCSVMHEALHNHYTQKSL SLSPGK

The ActRIIA-hFc and ActRIIA-mFc proteins were expressed in CHO celllines. Three different leader sequences were considered:

(i) Honey bee mellitin (HBML): (SEQ ID NO: 23) MKFLVNVALVFMVVYISYIYA(ii) Tissue plasminogen activator (TPA): (SEQ ID NO: 24)MDAMKRGLCCVLLLCGAVFVSP (iii) Native: (SEQ ID NO: 25)MGAAAKLAFAVFLISCSSGA.

The selected form employs the TPA leader and has the followingunprocessed amino acid sequence:

(SEQ ID NO: 26) MDAMKRGLCCVLLLCGAVFVSPGAAILGRSETQECLFFNANWEKDRTNQTGVEPCYGDKDKRRHCFATWKNISGSIEIVKQGCWLDDINCYDRTDCVEKKDSPEVYFCCCEGNMCNEKFSYFPEMEVTQPTSNPVTPKPPTGGGTHTCPPCPAPELLGGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSHEDPEVKFNWYVDGVEVHNAKTKPREEQYNSTYRVVSVLTVLHQDWLNGKEYKCKVSNKALPVPIEKTISKAKGQPREPQVYTLPPSREEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQGNVFSCSVM HEALHNHYTQKSLSLSPGK

This polypeptide is encoded by the following nucleic acid sequence:

(SEQ ID NO: 27) ATGGATGCAATGAAGAGAGGGCTCTGCTGTGTGCTGCTGCTGTGTGGAGCAGTCTTCGTTTCGCCCGGCGCCGCTATACTTGGTAGATCAGAAACTCAGGAGTGTCTTTTTTTAATGCTAATTGGGAAAAAGACAGAACCAATCAAACTGGTGTTGAACCGTGTTATGGTGACAAAGATAAACGGCGGCATTGTTTTGCTACCTGGAAGAATATTTCTGGTTCCATTGAATAGTGAAACAAGGTTGTTGGCTGGATGATATCAACTGCTATGACAGGACTGATTGTGTAGAAAAAAAAGACAGCCCTGAAGTATATTTCTGTTGCTGTGAGGGCAATATGTGTAATGAAAAGTTTTCTTATTTTCCGGAGATGGAAGTCACACAGCCCACTTCAAATCCAGTTACACCTAAGCCACCCACCGGTGGTGGAACTCACACATGCCCACCGTGCCCAGCACCTGAACTCCTGGGGGGACCGTCAGTCTTCCTCTTCCCCCCAAAACCCAAGGACACCCTCATGATCTCCCGGACCCCTGAGGTCACATGCGTGGTGGTGGACGTGAGCCACGAAGACCCTGAGGTCAAGTTCAACTGGTACGTGGACGGCGTGGAGGTGCATAATGCCAAGACAAAGCCGCGGGAGGAGCAGTACAACAGCACGTACCGTGTGGTCAGCGTCCTCACCGTCCTGCACCAGGACTGGCTGAATGGCAAGGAGTACAAGTGCAAGGTCTCCAACAAAGCCCTCCCAGTCCCCATCGAGAAAACCATCTCCAAAGCCAAAGGGCAGCCCCGAGAACCACAGGTGTACACCCTGCCCCCATCCCGGGAGGAGATGACCAAGAACCAGGTCAGCCTGACCTGCCTGGTCAAAGGCTTCTATCCCAGCGACATCGCCGTGGAGTGGGAGAGCAATGGGCAGCCGGAGAACAACTACAAGACCACGCCTCCCGTGCTGGACTCCGACGGCTCCTTCTTCCTCTATAGCAAGCTCACCGTGGACAAGAGCAGGTGGCAGCAGGGGAACGTCTTCTCATGCTCCGTGATGCATGAGGCTCTGCACAACCACTACACGCAGAAGAGCCTCTCCCTGTCTCCGG GTAAATGAGAATTC

Both ActRIIA-hFc and ActRIIA-mFc were remarkably amenable to recombinantexpression. As shown in FIGS. 3A and 3B, the protein was purified as asingle, well-defined peak of protein. N-terminal sequencing revealed asingle sequence of ILGRSETQE (SEQ ID NO:34). Purification could beachieved by a series of column chromatography steps, including, forexample, three or more of the following, in any order: protein Achromatography, Q sepharose chromatography, phenylsepharosechromatography, size exclusion chromatography, and cation exchangechromatography. The purification could be completed with viralfiltration and buffer exchange. The ActRIIA-hFc protein was purified toa purity of >98% as determined by size exclusion chromatography and >95%as determined by SDS PAGE.

ActRIIA-hFc and ActRIIA-mFc showed a high affinity for ligands,particularly activin A. GDF-11 or activin A were immobilized on aBiacore™ CM5 chip using standard amine coupling procedure. ActRIIA-hFcand ActRIIA-mFc proteins were loaded onto the system, and binding wasmeasured. ActRIIA-hFc bound to activin with a dissociation constant(K_(D)) of 5×10⁻¹², and bound to GDF11 with a K_(D) of 9.96×10⁻⁹. SeeFIGS. 4A and 4B. ActRIIA-mFc behaved similarly.

The ActRIIA-hFc was very stable in pharmacokinetic studies. Rats weredosed with 1 mg/kg, 3 mg/kg or 10 mg/kg of ActRIIA-hFc protein andplasma levels of the protein were measured at 24, 48, 72, 144 and 168hours. In a separate study, rats were dosed at 1 mg/kg, 10 mg/kg or 30mg/kg. In rats, ActRIIA-hFc had an 11-14 day serum half-life andcirculating levels of the drug were quite high after two weeks (11μg/ml, 110 μg/ml or 304 μg/ml for initial administrations of 1 mg/kg, 10mg/kg or 30 mg/kg, respectively.) In cynomolgus monkeys, the plasmahalf-life was substantially greater than 14 days and circulating levelsof the drug were 25 μg/ml, 304 μg/ml or 1440 μg/ml for initialadministrations of 1 mg/kg, 10 mg/kg or 30 mg/kg, respectively.

Example 2 Characterization of an ActRIIA-hFc Protein

ActRIIA-hFc fusion protein was expressed in stably transfected CHO-DUKXB11 cells from a pAID4 vector (SV40 ori/enhancer, CMV promoter), using atissue plasminogen leader sequence of SEQ ID NO:24. The protein,purified as described above in Example 1, had a sequence of SEQ IDNO:22. The Fc portion is a human IgG1 Fc sequence, as shown in SEQ IDNO:22. Protein analysis reveals that the ActRIIA-hFc fusion protein isformed as a homodimer with disulfide bonding.

Example 3 ActRIIA-hFc Increases Red Blood Cell Levels in Non-HumanPrimates

The study employed four groups of five male and five female cynomolgusmonkeys each, with three per sex per group scheduled for termination onDay 29, and two per sex per group scheduled for termination on Day 57.Each animal was administered the vehicle (Group I) or ActRIIA-Fc atdoses of 1, 10, or 30 mg/kg (Groups 2, 3 and 4, respectively) viaintravenous (IV) injection on Days 1, 8, 15 and 22. The dose volume wasmaintained at 3 mL/kg. Various measures of red blood cell levels wereassessed two days prior to the first administration and at days 15, 29and 57 (for the remaining two animals) after the first administration.

The ActRIIA-hFc caused statistically significant increases in mean redblood cell parameters [red blood cell count (RBC, hemoglobin (HGB), andhematocrit (HCT)] for males and females, at all dose levels and timepoints throughout the study, with accompanying elevations in absoluteand relative reticulocyte counts (ARTC; RTC). See FIGS. 5-8.

Statistical significance was calculated for each treatment grouprelative to the mean for the treatment group at baseline.

Notably, the increases in red blood cell counts and hemoglobin levelsare roughly equivalent in magnitude to effects reported witherythropoietin. The onset of these effects is more rapid with ActRIIA-Fcthan with erythropoietin.

Similar results were observed with rats and mice.

Example 4 ActRIIA-hFc Increases Red Blood Cell Levels and Markers ofBone Formation in Human Patients

The ActRIIA-hFc fusion protein described in Example 1 was administeredto human patients in a randomized, double-blind, placebo-controlledstudy that was conducted to evaluate, primarily, the safety of theprotein in healthy, postmenopausal women. Forty-eight subjects wererandomized in cohorts of 6 to receive either a single dose ofActRIIA-hFc or placebo (5 active:1 placebo). Dose levels ranged from0.01 to 3.0 mg/kg intravenously (IV) and 0.03 to 0.1 mg/kgsubcutaneously (SC). All subjects were followed for 120 days. Inaddition to pharmacokinetic (PK) analyses, the biologic activity ofActRIIA-hFc was also assessed by measurement of biochemical markers ofbone formation and resorption as well as FSH levels.

To look for potential changes, hemoglobin and RBC numbers were examinedin detail for all subjects over the course of the study and compared tothe baseline levels. Platelet counts were compared over the same time asthe control. There were no clinically significant changes from thebaseline values over time for the platelet counts.

PK analysis of ActRIIA-hFc revealed a linear profile with dose, and amean half-life of approximately 25-32 days. The area-under-curve (AUC)for ActRIIA-hFc was linearly related to dose, and the absorption afterSC dosing was essentially complete. See FIGS. 9 and 10. These dataindicate that SC is a desirable approach to dosing because it providesequivalent bioavailability and serum-half life for the drug whileavoiding the spike in serum concentrations of drug associated with thefirst few days of IV dosing. See FIG. 10. ActRIIA-hFc caused a rapid,sustained dose-dependent increase in serum levels of bone-specificalkaline phosphatase (BAP), which is a marker for anabolic bone growth,and a dose-dependent decrease in C-terminal type 1 collagen telopeptideand tartrate-resistant acid phosphatase 5b levels, which are markers forbone resorption. Other markers, such as P1NP showed inconclusiveresults. BAP levels showed near saturating effects at the highest dosageof drug, indicating that half-maximal effects on this anabolic bonebiomarker could be achieved at a dosage of 0.3 mg/kg, with increasesranging up to 3 mg/kg. Calculated as a relationship of pharmacodynamiceffect to AUC for drug, the EC50 was 51,465 (day*ng/ml). See FIG. 11.These bone biomarker changes were sustained for approximately 120 daysat the highest dose levels tested. There was also a dose-dependentdecrease in serum FSH levels consistent with inhibition of activin.

Overall, there was a very small non-drug related reduction in hemoglobinover the first week of the study probably related to study phlebotomy inthe 0.01 and 0.03 mg/kg groups whether given IV or SC. The 0.1 mg/kg SCand IV hemoglobin results were stable or showed modest increases by Day8-15. At the 0.3 mg/kg IV dose level there was a clear increase in HGBlevels seen as early as Day 2 and often peaking at Day 15-29 that wasnot seen in the placebo-treated subjects. At the 1.0 mg/kg IV dose andthe 3.0 mg/kg IV dose, mean increases in hemoglobin of greater than 1g/dl were observed in response to the single dose, with correspondingincreases in RBC counts and hematocrit. These hematologic parameterspeaked at about 60 days after the dose and substantial decrease by day120. This indicates that dosing for the purpose of increasing red bloodcell levels may be more effective if done at intervals less than 120days (i.e., prior to return to baseline), with dosing intervals of 90days or less or 60 days or less may be desirable. For a summary ofhematological changes, see FIGS. 12-15.

Overall, ActRIIA-hFc showed a dose-dependent effect on red blood cellcounts and reticulocyte counts.

Example 5 Treatment of an Anemic Patient with ActRIIA-hFc

A clinical study was designed to treat patients with multiple doses ofActRIIA-hFc, at 30 dose levels of 0.1 mg/kg, 0.3 mg/kg, and 1.0 mg/kg,with dosing to occur every thirty days. Normal healthy patients in thetrial exhibited an increase in hemoglobin and hematocrit that isconsistent with the increases seen in the Phase I clinical trialreported in Example 4, except that in some instances, the hemoglobin(Hg) and hematocrit (Hct) are elevated beyond the normal range. Ananemic patient with hemoglobin levels of approximately 7.5 g/dL alsoreceived two doses at the 1 mg/kg level, resulting in a hemoglobin levelof approximately 10.5 g/dL after two months. The patient's anemia was amicrocytic anemia, thought to be caused by chronic iron deficiency.

ActRIIA-Fc fusion proteins have been further demonstrated to beeffective in increasing red blood cell levels in various models ofanemia including, for example, chemotherapy-induced anemia and anemiaassociated with chronic kidney disease. See, e.g., U.S. PatentApplication Publication No. 2010/0028331.

Example 6 Alternative ActRIIA-Fc Proteins

A variety of ActRIIA variants that may be used according to the methodsdescribed herein are described in the International Patent Applicationpublished as WO2006/012627 (see e.g., pp. 59-60), incorporated herein byreference in its entirety. An alternative construct may have a deletionof the C-terminal tail (the final 15 amino acids of the extracellulardomain of ActRIIA. The sequence for such a construct is presented below(Fe portion underlined) (SEQ ID NO:28):

ILGRSETQECLFFNANWEKDRTNQTGVEPCYGDKDKRRHCFATWKNISGSIEIVKQGCWLDDINCYDRTDCVEKKDSPEVYFCCCEGNMCNEKFSYFPEMTGGGTHTCPPCPAPELLGGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSHEDPEVKFNWYVDGVEVHNAKTKPREEQYNSTYRVVSVLTVLHQDWLNGKEYKCKVSNKALPVPIEKTISKAKGQPREPQVYTLPPSREEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQGNVFSCSVMHEALHNHYTQKSLSLSPGK

Example 7 Generation of ActRIIB-Fc Fusion Proteins

Applicant constructed a soluble ActRIIB fusion protein that has theextracellular domain of human ActRIIB fused to a human or mouse Fcdomain with a minimal linker (three glycine amino acids) in between. Theconstructs are referred to as ActRIIB-hFc and ActRIIB-mFc, respectively.

ActRIIB-hFc is shown below as purified from CHO cell lines (SEQ IDNO:29)

GRGEAETRECIYYNANWELERTNQSGLERCEGEQDKRLHCYASWRNSSGTIELVKKGCWLDDFNCYDRQECVATEENPQVYFCCCEGNFCNERFTHLPEAGGPEVTYEPPPTAPTGGGTHTCPPCPAPELLGGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSHEDPEVKFNWYVDGVEVHNAKTKPREEQYNSTYRVVSVLTVLHQDWLNGKEYKCKVSNKALPVPIEKTISKAKGQPREPQVYTLPPSREEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQGNVFSCSVMHEALHNHYTQKSLSLSPGK

The ActRIIB-hFc and ActRIIB-mFc proteins were expressed in CHO celllines. Three different leader sequences were considered:

-   (i) Honey bee mellitin (HBML): MKFLVNVALVFMVVYISYIYA (SEQ ID NO:23)-   (ii) Tissue plasminogen activator (TPA): MDAMKRGLCCVLLLCGAVFVSP (SEQ    ID NO:24)    -   (iii) Native: MTAPWVALALLWGSLCAGS (SEQ ID NO:30).

The selected form employs the TPA leader and has the followingunprocessed amino acid sequence (SEQ ID NO: 31):

MDAMKRGLCCVLLLCGAVFVSPGASGRGEAETRECIYYNANWELERTNQSGLERCEGEQDKRLHCYASWRNSSGTIELVKKGCWLDDFNCYDRQECVATEENPQVYFCCCEGNFCNERFTHLPEAGGPEVTYEPPPTAPTGGGTHTCPPCPAPELLGGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSHEDPEVKFNWYVDGVEVHNAKTKPREEQYNSTYRVVSVLTVLHQDWLNGKEYKCKVSNKALPVPIEKTISKAKGQPREPQVYTLPPSREEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQGNVFSCSVMH EALHNHYTQKSLSLSPGK

This polypeptide is encoded by the following nucleic acid sequence (SEQID NO:32):

A TGGATGCAAT GAAGAGAGGG CTCTGCTGTG TGCTGCTGCTGTGTGGAGCA GTCTTCGTTT CGCCCGGCGC CTCTGGGCGTGGGGAGGCTG AGACACGGGA GTGCATCTAC TACAACGCCAACTGGGAGCT GGAGCGCACC AACCAGAGCG GCCTGGAGCGCTGCGAAGGC GAGCAGGACA AGCGGCTGCA CTGCTACGCCTCCTGGCGCA ACAGCTCTGG CACCATCGAG CTCGTGAAGAAGGGCTGCTG GCTAGATGAC TTCAACTGCT ACGATAGGCAGGAGTGTGTG GCCACTGAGG AGAACCCCCA GGTGTACTTCTGCTGCTGTG AAGGCAACTT CTGCAACGAG CGCTTCACTCATTTGCCAGA GGCTGGGGGC CCGGAAGTCA CGTACGAGCCACCCCCGACA GCCCCCACCG GTGGTGGAAC TCACACATGCCCACCGTGCC CAGCACCTGA ACTCCTGGGG GGACCGTCAGTCTTCCTCTT CCCCCCAAAA CCCAAGGACA CCCTCATGATCTCCCGGACC CCTGAGGTCA CATGCGTGGT GGTGGACGTGAGCCACGAAG ACCCTGAGGT CAAGTTCAAC TGGTACGTGGACGGCGTGGA GGTGCATAAT GCCAAGACAA AGCCGCGGGAGGAGCAGTAC AACAGCACGT ACCGTGTGGT CAGCGTCCTCACCGTCCTGC ACCAGGACTG GCTGAATGGC AAGGAGTACAAGTGCAAGGT CTCCAACAAA GCCCTCCCAG TCCCCATCGAGAAAACCATC TCCAAAGCCA AAGGGCAGCC CCGAGAACCACAGGTGTACA CCCTGCCCCC ATCCCGGGAG GAGATGACCAAGAACCAGGT CAGCCTGACC TGCCTGGTCA AAGGCTTCTATCCCAGCGAC ATCGCCGTGG AGTGGGAGAG CAATGGGCAGCCGGAGAACA ACTACAAGAC CACGCCTCCC GTGCTGGACTCCGACGGCTC CTTCTTCCTC TATAGCAAGC TCACCGTGGACAAGAGCAGG TGGCAGCAGG GGAACGTCTT CTCATGCTCCGTGATGCATG AGGCTCTGCA CAACCACTAC ACGCAGAAGA GCCTCTCCCT GTCTCCGGGT AAATGA

N-terminal sequencing of the CHO-cell produced material revealed a majorpolypeptide sequence of -GRGEAE (SEQ ID NO:33). Notably, otherconstructs reported in the literature begin with an -SGR . . . sequence.

Purification could be achieved by a series of column chromatographysteps, including, for example, three or more of the following, in anyorder: protein A chromatography, Q sepharose chromatography,phenylsepharose chromatography, size exclusion chromatography, andcation exchange chromatography. The purification could be completed withviral filtration and buffer exchange.

ActRIIB-Fc fusion proteins were also expressed in HEK293 cells and COScells. Although material from all cell lines and reasonable cultureconditions provided protein with muscle-building activity in vivo,variability in potency was observed perhaps relating to cell lineselection and/or culture conditions.

Applicant generated a series of mutations in the extracellular domain ofActRIIB and produced these mutant proteins as soluble fusion proteinsbetween extracellular ActRIIB and an Fc domain. The backgroundActRIIB-Fc fusion has the sequence of SEQ ID NO:29.

Various mutations, including N-and C-terminal truncations, wereintroduced into the background ActRIIB-Fc protein. Based on the datapresented in Example 1, it is expected that these constructs, ifexpressed with a TPA leader, will lack the N-terminal serine. Mutationswere generated in ActRIIB extracellular domain by PCR mutagenesis. AfterPCR, fragments were purified through a Qiagen column, digested with SfoIand AgeI and gel purified. These fragments were ligated into expressionvector pAID4 (see WO2006/012627) such that upon ligation it createdfusion chimera with human IgG1. Upon transformation into E. coli DH5alpha, colonies were picked and DNAs were isolated. For murineconstructs (mFc), a murine IgG2a was substituted for the human IgG1.Sequences of all mutants were verified.

All of the mutants were produced in HEK293T cells by transienttransfection. In summary, in a 500 ml spinner, HEK293T cells were set upat 6×10⁵ cells/ml in Freestyle (Invitrogen) media in 250 ml volume andgrown overnight. Next day, these cells were treated with DNA:PEI (1:1)complex at 0.5 ug/ml final DNA concentration. After 4 hrs, 250 ml mediawas added and cells were grown for 7 days. Conditioned media washarvested by spinning down the cells and concentrated.

Mutants were purified using a variety of techniques, including, forexample, a protein A column and eluted with low pH (3.0) glycine buffer.After neutralization, these were dialyzed against PBS.

Mutants were also produced in CHO cells by similar methodology.

Mutants were tested in binding assays and/or bioassays described in WO2008/097541 and WO 2006/012627 incorporated by reference herein. In someinstances, assays were performed with conditioned medium rather thanpurified proteins. Additional variations of ActRIIB are described inU.S. Pat. No. 7,842,663.

Example 8 ActRIIB-Fc Stimulates Erythropoiesis in Non-Human Primates

Cynomolgus monkeys were allocated into seven groups (6/sex/group) andadministered ActRIIB(20-134)-hFc as a subcutaneous injection at dosagesof 0.6, 3, or 15 mg/kg every 2 weeks or every 4 weeks over a 9 monthperiod. The control group (6/sex/group) received the vehicle at the samedose volume (0.5 ml/kg/dose) as ActRIIB(20-134)-hFc-treated animals.Animals were monitored for changes in general clinical pathologyparameters (e.g., hematology, clinical chemistry, coagulation, andurinalysis). Hematology, coagulation, and clinical chemistry parameters(including iron parameters, lipase, and amylase) were evaluated twiceprior to initiation of dosing and on Days 59, 143, 199, 227, and on Days267 (for groups dosed every 4 weeks) or 281 (for groups dosed every 2weeks). The evaluations on Days 267/281 occurred 2 weeks after the finaldose was administered.

Administration of ActRIIB(20-134)-hFc resulted in non-adverse,dose-related changes to hematology parameters in male and femalemonkeys. These changes included increased red blood cell count,reticulocyte count and red cell distribution width and decreased meancorpuscular volume, mean corpuscular hemoglobin, and platelet count. Inmales, RBC count was increased at all dose levels and the magnitude ofincrease was generally comparable whether ActRIIB(20-134)-hFc wasadministered every 2 weeks or every 4 weeks. Mean RBC count wasincreased at all time points between Days 59 and 267/281 (except RBCcount was not increased in Group 2 males [0.6 mg/kg every 2 weeks] onDay 281). In females, RBC count was increased at >3 mg/kg every 2 weeksand the changes occurred between Days 143 and 281; at 15 mg/kg every 4weeks mean RBC count was increased between Days 59 and 267.

These effects are consistent with a positive effect ofActRIIB(20-134)-hFc on stimulating erythropoiesis.

Example 9 Generation of a GDF Trap

Applicant constructed a GDF Trap as follows. A polypeptide having amodified extracellular domain of ActRIIB (amino acids 20-134 of SEQ IDNO:1 with an L79D substition) with greatly reduced activin A bindingrelative to GDF11 and/or myostatin (as a consequence of aleucine-to-aspartate substitution at position 79 in SEQ ID NO:1) wasfused to a human or mouse Fc domain with a minimal linker (three glycineamino acids) in between. The constructs are referred to as ActRIIB(L79D20-134)-hFc and ActRIIB(L79D 20-134)-mFc, respectively. Alternativeforms with a glutamate rather than an aspartate at position 79 performedsimilarly (L79E). Alternative forms with an alanine rather than a valineat position 226 with respect to SEQ ID NO:36, below were also generatedand performed equivalently in all respects tested. The aspartate atposition 79 (relative to SEQ ID NO: 1, or position 60 relative to SEQ IDNO:36) is indicated with double underlining below. The valine atposition 226 relative to SEQ ID NO:36 is also indicated by doubleunderlining below.

The GDF Trap ActRIIB(L79D 20-134)-hFc is shown below as purified fromCHO cell lines (SEQ ID NO:36).

GRGEAETRECIYYNANWELERTNQSGLERCEGEQDKRLHCYASWRNSSGTIELVKKGCWDDDFNCYDRQECVATEENPQVYFCCCEGNFCNERFTHLPEAGGPEVTYEPPPTAPTGGGTHTCPPCPAPELLGGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSHEDPEVKFNWYVDGVEVHNAKTKPREEQYNSTYRVVSVLTVLHQDWLNGKEYKCKVSNKALP V PIEKTISKAKGQPREPQVYTLPPSREEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQGNVFSCSVMHEALHNHYTQKSLSLSPGK

The ActRIIB-derived portion of the GDF Trap has an amino acid sequenceset forth below (SEQ ID NO: 37), and that portion could be used as amonomer or as a non-Fc fusion protein as a monomer, dimer or greaterorder complex.

(SEQ ID NO: 37) GRGEAETRECIYYNANWELERTNQSGLERCEGEQDKRLHCYASWRNSSGTIELVKKGCWDDDFNCYDRQECVATEENPQVYFCCCEGNFCNERFTHLPEA GGPEVTYEPPPTAPT

The GDF Trap protein was expressed in CHO cell lines. Three differentleader sequences were considered:

(i) Honey bee melittin (HBML): (SEQ ID NO: 23) MKFLVNVALVFMVVYISYIYA(ii) Tissue plasminogen activator (TPA): (SEQ ID NO: 24)MDAMKRGLCCVLLLCGAVFVSP (iii) Native: (SEQ ID NO: 30)MTAPWVALALLWGSLCAGS.

The selected form employs the TPA leader and has the followingunprocessed amino acid sequence:

(SEQ ID NO: 38) MDAMKRGLCCVLLLCGAVFVSPGASGRGEAETRECIYYNANWELERTNQSGLERCEGEQDKRLHCYASWRNSSGTIELVKKGCWDDDFNCYDRQECVATEENPQVYFCCCEGNFCNERFTHLPEAGGPEVTYEPPPTAPTGGGTHTCPPCPAPELLGGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSHEDPEVKFNWYVDGVEVHNAKTKPREEQYNSTYRVVSVLTVLHQDWLNGKEYKCKVSNKALPAPIEKTISKAKGQPREPQVYTLPPSREEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQGNVFSCSVMH EALHNHYTQKSLSLSPGK

This polypeptide is encoded by the following nucleic acid sequence (SEQID NO:68):

A TGGATGCAAT GAAGAGAGGG CTCTGCTGTG TGCTGCTGCTGTGTGGAGCA GTCTTCGTTT CGCCCGGCGC CTCTGGGCGTGGGGAGGCTG AGACACGGGA GTGCATCTAC TACAACGCCAACTGGGAGCT GGAGCGCACC AACCAGAGCG GCCTGGAGCGCTGCGAAGGC GAGCAGGACA AGCGGCTGCA CTGCTACGCCTCCTGGCGCA ACAGCTCTGG CACCATCGAG CTCGTGAAGAAGGGCTGCTG GGACGATGAC TTCAACTGCT ACGATAGGCAGGAGTGTGTG GCCACTGAGG AGAACCCCCA GGTGTACTTCTGCTGCTGTG AAGGCAACTT CTGCAACGAG CGCTTCACTCATTTGCCAGA GGCTGGGGGC CCGGAAGTCA CGTACGAGCCACCCCCGACA GCCCCCACCG GTGGTGGAAC TCACACATGCCCACCGTGCC CAGCACCTGA ACTCCTGGGG GGACCGTCAGTCTTCCTCTT CCCCCCAAAA CCCAAGGACA CCCTCATGATCTCCCGGACC CCTGAGGTCA CATGCGTGGT GGTGGACGTGAGCCACGAAG ACCCTGAGGT CAAGTTCAAC TGGTACGTGGACGGCGTGGA GGTGCATAAT GCCAAGACAA AGCCGCGGGAGGAGCAGTAC AACAGCACGT ACCGTGTGGT CAGCGTCCTCACCGTCCTGC ACCAGGACTG GCTGAATGGC AAGGAGTACAAGTGCAAGGT CTCCAACAAA GCCCTCCCAG TCCCCATCGAGAAAACCATC TCCAAAGCCA AAGGGCAGCC CCGAGAACCACAGGTGTACA CCCTGCCCCC ATCCCGGGAG GAGATGACCAAGAACCAGGT CAGCCTGACC TGCCTGGTCA AAGGCTTCTATCCCAGCGAC ATCGCCGTGG AGTGGGAGAG CAATGGGCAGCCGGAGAACA ACTACAAGAC CACGCCTCCC GTGCTGGACTCCGACGGCTC CTTCTTCCTC TATAGCAAGC TCACCGTGGACAAGAGCAGG TGGCAGCAGG GGAACGTCTT CTCATGCTCCGTGATGCATG AGGCTCTGCA CAACCACTAC ACGCAGAAGA GCCTCTCCCT GTCTCCGGGT AAATGA

Purification could be achieved by a series of column chromatographysteps, including, for example, three or more of the following, in anyorder: protein A chromatography, Q sepharose chromatography,phenylsepharose chromatography, size exclusion chromatography, andcation exchange chromatography. The purification could be completed withviral filtration and buffer exchange. In an example of a purificationscheme, the cell culture medium is passed over a protein A column,washed in 150 mM Tris/NaCl (pH 8.0), then washed in 50 mM Tris/NaCl (pH8.0) and eluted with 0.1 M glycine, pH 3.0. The low pH eluate is kept atroom temperature for 30 minutes as a viral clearance step. The eluate isthen neutralized and passed over a Q sepharose ion exchange column andwashed in 50 mM Tris pH 8.0, 50 mM NaCl, and eluted in 50 mM Tris pH8.0. with an NaCl concentration between 150 mM and 300 mM. The eluate isthen changed into 50 mM Tris pH 8.0, 1.1 M ammonium sulfate and passedover a phenyl sepharose column, washed, and eluted in 50 mM Tris pH 8.0with ammonium sulfate between 150 and 300 mM. The eluate is dialyzed andfiltered for use.

Additional GDF Traps (ActRIIB-Fc fusion proteins modified so as toreduce the ratio of activin A binding relative to myostatin or GDF11binding) are described in WO 2008/097541 and WO 2006/012627,incorporated by reference herein.

Example 10 Bioassay for GDF-11 and Activin-Mediated Signaling

An A-204 reporter gene assay was used to evaluate the effects ofActRIIB-Fc proteins and GDF Traps on signaling by GDF-11 and activin A.Cell line: human rhabdomyosarcoma (derived from muscle). Reportervector: pGL3(CAGA)12 (described in Dennler et al, 1998, EMBO 17:3091-3100). The CAGA12 motif is present in TGF-Beta responsive genes(e.g., PAI-1 gene), so this vector is of general use for factorssignaling through SMAD2 and 3.

Day 1: Split A-204 cells into 48-well plate.

Day 2: A-204 cells transfected with 10 ug pGL3(CAGA)12 orpGL3(CAGA)12(10 ug)+pRLCMV (1 μg) and Fugene.

Day 3: Add factors (diluted into medium+0.1% BSA). Inhibitors need to bepreincubated with factors for 1 hr before adding to cells. Six hrslater, cells were rinsed with PBS, and lysed.

This is followed by a luciferase assay. In the absence of anyinhibitors, Activin A showed 10-fold stimulation of reporter geneexpression and an ED50˜2 ng/ml. GDF-11: 16 fold stimulation, ED50: ˜1.5ng/ml.

ActRIIB(20-134) is a potent inhibitor of activin A, GDF-8, and GDF-11activity in this assay. As described below ActRIIB variants were alsotested in this assay.

Example 11 ActRIIB-Fc Variants, Cell-Based Activity

Activity of ActRIIB-Fc proteins and GDF Traps was tested in a cell basedassay, as described above. Results are summarized in the table below.Some variants were tested in different C-terminal truncation constructs.As discussed above, truncations of five or fifteen amino acids causedreduction in activity. The GDF Traps (L79D and L79E variants) showedsubstantial loss of activin A inhibition while retaining almostwild-type inhibition of GDF-11.

Soluble ActRIIB-Fc binding to GDF11 and Activin A:

Portion of ActRIIB GDF11 Activin ActRIIB-Fc (corresponds to aminoInhibition Inhibition Variations acids of SEQ ID NO: 1) ActivityActivity R64 20-134 +++ +++ (approx. (approx. 10⁻⁸M K_(I)) 10⁻⁸M K_(I))A64 20-134 + + (approx. (approx. 10⁻⁶M K_(I)) 10⁻⁶M K_(I)) R64 20-129+++ +++ R64 K74A 20-134 ++++ ++++ R64 A24N 20-134 +++ +++ R64 A24N20-119 ++ ++ R64 A24N K74A 20-119 + + R64 L79P 20-134 + + R64 L79P K74A20-134 + + R64 L79D 20-134 +++ + R64 L79E 20-134 +++ + R64K 20-134 ++++++ R64K 20-129 +++ +++ R64 P129S P130A 20-134 +++ +++ R64N 20-134 + + +Poor activity (roughly 1 × 10⁻⁶ K_(I)) ++ Moderate activity (roughly 1 ×10⁻⁷ K_(I)) +++ Good (wild-type) activity (roughly 1 × 10⁻⁸ K_(I)) ++++Greater than wild-type activity

Several variants have been assessed for serum half-life in rats.ActRIIB(20-134)-Fc has a serum half-life of approximately 70 hours.ActRIIB(A24N 20-134)-Fc has a serum half-life of approximately 100-150hours. The A24N variant has activity in the cell-based assay (above) andin vivo assays (below) that is equivalent to the wild-type molecule.Coupled with the longer half-life, this means that over time an A24Nvariant will give greater effect per unit of protein than the wild-typemolecule. The A24N variant, and any of the other variants tested above,may be combined with the GDF Trap molecules, such as the L79D or L79Evariants.

Example 12 GDF-1 and Activin A Binding

Binding of certain ActRIIB-Fc proteins and GDF Traps to ligands wastested in a Biacore™ assay.

The ActRIIB-Fc variants or wild-type protein were captured onto thesystem using an anti-hFc antibody. Ligands were injected and flowed overthe captured receptor proteins. Results are summarized in the tables,below.

Ligand-Binding Specificity IIB Variants.

Protein Kon (1/Ms) Koff (1/s) KD (M) GDF11 ActRIIB(20-134)-hFc 1.34e−61.13e−4 8.42e−11 ActRIIB(A24N 20-134)-hFc 1.21e−6 6.35e−5 5.19e−11ActRIIB(L79D 20-134)-hFc  6.7e−5 4.39e−4 6.55e−10 ActRIIB(L79E20-134)-hFc  3.8e−5 2.74e−4 7.16e−10 ActRIIB(R64K 20-134)-hFc 6.77e−52.41e−5 3.56e−11 GDF8 ActRIIB(20-134)-hFc 3.69e−5 3.45e−5 9.35e−11ActRIIB(A24N 20-134)-hFc ActRIIB(L79D 20-134)-hFc 3.85e−5  8.3e−42.15e−9  ActRIIB(L79E 20-134)-hFc 3.74e−5   9e−4 2.41e−9  ActRIIB(R64K20-134)-hFc 2.25e−5 4.71e−5  2.1e−10 ActRIIB(R64K 20-129)-hFc 9.74e−42.09e−4 2.15e−9  ActRIIB(P129S, P130R 20- 1.08e−5  1.8e−4 1.67e−9 134)-hFc ActRIIB(K74A 20-134)-hFc  2.8e−5 2.03e−5 7.18e−11 Activin AActRIIB(20-134)-hFc 5.94e6  1.59e−4 2.68e−11 ActRIIB(A24N 20-134)-hFc3.34e6  3.46e−4 1.04e−10 ActRIIB(L79D 20-134)-hFc Low bindingActRIIB(L79E 20-134)-hFc Low binding ActRIIB(R64K 20-134)-hFc 6.82e6 3.25e−4 4.76e−11 ActRIIB(R64K 20-129)-hFc 7.46e6  6.28e−4 8.41e−11ActRIIB(P129S, P130R 20- 5.02e6  4.17e−4 8.31e−11 134)-hFc

These data obtained from a cell-free assay confirm the cell based assaydata, demonstrating that the A24N variant retains ligand-bindingactivity that is similar to that of the ActRIIB(20-134)-hFc molecule,and that the L79D or L79E molecule retains myostatin and GDF11 bindingbut shows markedly decreased (non-quantifiable) binding to activin A.

Other variants have been generated and tested, as reported inWO2006/012627 (incorporated herein by reference in its entirety) See,e.g., pp. 59-60, using ligands coupled to the device and flowingreceptor over the coupled ligands. Notably, K74Y, K74F, K741 (andpresumably other hydrophobic substitutions at K74, such as K74L), andD80I, cause a decrease in the ratio of activin A (ActA) binding to GDF11binding, relative to the wild-type K74 molecule. A table of data withrespect to these variants is reproduced below:

Soluble ActRIIB-Fc Variants Binding to GDF11 and Activin a (BiaCoreAssay)

ActRIIB ActA GDF11 WT (64A) KD = 1.8e−7M KD = 2.6e−7M (+) (+) WT (64R)na KD = 8.6e−8M (+++) +15tail KD ~2.6e−8M KD = 1.9e−8M (+++) (++++)E37A * * R40A − − D54A − * K55A ++ * R56A * * K74A KD = 4.35e−9M KD =5.3e−9M +++++ +++++ K74Y * −− K74F * −− K74I * −− W78A * * L79A + *D80K * * D80R * * D80A * * D80F * * D80G * * D80M * * D80N * * D80I * −−F82A ++ − * No observed binding −− <⅕ WT binding − ~½ WT binding + WT ++<2x increased binding +++ ~5x increased binding ++++ ~10x increasedbinding +++++ ~40x increased binding

Example 13 A GDF Trap Increases Red Blood Cell Levels In Vivo

Twelve-week-old male C57BL/6NTac mice were assigned to one of twotreatment groups (N=10). Mice were dosed with either vehicle or with avariant ActRIIB polypeptide (“GDF Trap”) [ActRIIB(L79D 20-134)-hFc] bysubcutaneous injection (SC) at 10 mg/kg twice per week for 4 weeks. Atstudy termination, whole blood was collected by cardiac puncture intoEDTA containing tubes and analyzed for cell distribution using an HM2hematology analyzer (Abaxis, Inc).

Group Designation

Dose Group N Mice Injection (mg/kg) Route Frequency 1 10 C57BL/6 PBS 0SC Twice/ week 2 10 C57BL/6 GDF Trap 10 SC Twice/ [ActRIIB(L79D week20-134)-hFc]

Treatment with the GDF Trap did not have a statistically significanteffect on the number of white blood cells (WBC) compared to the vehiclecontrols. Red blood cell (RBC) numbers were increased in the treatedgroup relative to the controls (see table below). Both the hemoglobincontent (HGB) and hematocrit (HCT) were also increased due to theadditional red blood cells. The average width of the red blood cells(RDWc) was higher in the treated animals, indicating an increase in thepool of immature red blood cells. Therefore, treatment with the GDF Trapleads to increases in red blood cells, with no distinguishable effectson white blood cell populations.

Hematology Results

RBC HGB HCT RDWc 10¹²/L (g/dL) (%) (%) PBS 10.7 ± 0.1  14.8 ± 0.6  44.8± 0.4  17.0 ± 0.1  GDF Trap 12.4 ± 0.4** 17.0 ± 0.7* 48.8 ± 1.8* 18.4 ±0.2** *= p < 0.05, **= p < 0.01

Example 14 A GDF Trap is Superior to ActRIIB-Fc for Increasing Red BloodCell Levels In Vivo

Nineteen-week-old male C57BL/6NTac mice were randomly assigned to one ofthree groups. Mice were dosed with vehicle (10 mM Tris Buffered Saline,TBS), wild-type ActRIIB(20-134)-mFc, or GDF trap ActRIIB(L79D20-134)-hFc by subcutaneous injection twice per week for three weeks.Blood was collected cheek bleed at baseline and after three weeks ofdosing and analyzed for cell distribution using a hematology analyzer(HM2, Abaxis, Inc.)

Treatment with ActRIIB-Fc or the GDF trap did not have a significanteffect on white blood cell (WBC) numbers compared to vehicle controls.The red blood cell count (RBC), hematocrit (HCT), and hemoglobin levelswere all elevated in mice treated with GDF Trap compared to either thecontrols or the wild-type construct (see table below). Therefore, in adirect comparison, the GDF trap promotes increases in red blood cells toa significantly greater extent than a wild-type ActRIIB-Fc protein. Infact, in this experiment, the wild-type ActRIIB-Fc protein did not causea statistically significant increase in red blood cells, suggesting thatlonger or higher dosing would be needed to reveal this effect.

Hematology Results after Three Weeks of Dosing

RBC HGB (10¹²/ml) HCT % g/dL TBS 11.06 ± 0.46 46.78 ± 1.9 15.7 ± 0.7ActRIIB-mFc 11.64 ± 0.09 49.03 ± 0.3 16.5 ± 1.5 GDF Trap  13.19 ± 0.2** 53.04 ± 0.8**  18.4 ± 0.3** **= p < 0.01

Example 15 Generation of a GDF Trap with Truncated ActRIIB ExtracellularDomain

As described in Example 9, a GDF Trap referred to as ActRIIB(L79D20-134)-hFc was generated by N-terminal fusion of TPA leader to theActRIIB extracellular domain (residues 20-134 in SEQ ID NO:1) containinga leucine-to-aspartate substitution (at residue 79 in SEQ ID NO: 1) andC-terminal fusion of human Fc domain with minimal linker (three glycineresidues) (FIG. 16). A nucleotide sequence corresponding to this fusionprotein is shown in FIGS. 17A and 17B.

A GDF Trap with truncated ActRIIB extracellular domain, referred to asActRIIB(L79D 25-131)-hFc, was generated by N-terminal fusion of TPAleader to truncated extracellular domain (residues 25-131 in SEQ IDNO:1) containing a leucine-to-aspartate substitution (at residue 79 inSEQ ID NO:1) and C-terminal fusion of human Fc domain with minimallinker (three glycine residues) (FIG. 18). A nucleotide sequencecorresponding to this fusion protein is shown in FIGS. 19A and 19B.

Example 16 Selective Ligand Binding by GDF Trap with Double-TruncatedActRIIB Extracelluar Domain

The affinity of GDF Traps and other ActRIIB-hFc proteins for severalligands was evaluated in vitro with a Biacore™ instrument. Results aresummarized in the table below. Kd values were obtained by steady-stateaffinity fit due to the very rapid association and dissociation of thecomplex, which prevented accurate determination of k_(on) and k_(off).

Ligand Selectivity of ActRIIB-hFc Variants:

Activin A Activin B GDF11 Fusion Construct (Kd e−11) (Kd e−11) (Kd e−11)ActRIIB(L79 20-134)-hFc 1.6 1.2 3.6 ActRIIB(L79D 20-134)-hFc 1350.0 78.812.3 ActRIIB(L79 25-131)-hFc 1.8 1.2 3.1 ActRIIB(L79D 25-131)-hFc 2290.062.1 7.4

The GDF Trap with a truncated extracellular domain, ActRIIB(L79D25-131)-hFc, equaled or surpassed the ligand selectivity displayed bythe longer variant, ActRIIB(L79D 20-134)-hFc, with pronounced loss ofactivin A binding, partial loss of activin B binding, and nearly fullretention of GDF11 binding compared to ActRIIB-hFc counterparts lackingthe L79D substitution. Note that truncation alone (without L79Dsubstitution) did not alter selectivity among the ligands displayed here[compare ActRIIB(L79 25-131)-hFc with ActRIIB(L79 20-134)-hFc].

Example 17 Generation of ActRIIB(L79D 25-131)-hFc with AlternativeNucleotide Sequences

To generate ActRIIB(L79D 25-131)-hFc, the human ActRIIB extracellulardomain with an aspartate substitution at native position 79 (SEQ IDNO: 1) and with N-terminal and C-terminal truncations (residues 25-131in SEQ ID NO: 1) was fused N-terminally with a TPA leader sequenceinstead of the native ActRIIB leader and C-terminally with a human Fcdomain via a minimal linker (three glycine residues) (FIG. 18). Onenucleotide sequence encoding this fusion protein is shown in FIG. 19(SEQ ID NO: 42), and an alternative nucleotide sequence encoding exactlythe same fusion protein is shown in FIGS. 22A and 22B (SEQ ID NO: 46).This protein was expressed and purified using the methodology describedin Example 9.

Example 18 GDF Trap with a Truncated ActRIIB Extracellular DomainIncreases Proliferation of Erythroid Progenitors in Mice

ActRIIB(L79D 25-131)-hFc was evaluated to determine its effect onproliferation of erythroid progenitors. Male C57BL/6 mice (8 weeks old)were treated with ActRIIB(L79D 25-131)-hFc (10 mg/kg, s.c.; n=6) orvehicle (TBS; n=6) on Days 1 and 4, then euthanized on Day 8 forcollection of spleens, tibias, femurs, and blood. Cells of the spleenand bone marrow were isolated, diluted in Iscove's modified Dulbecco'smedium containing 5% fetal bovine serum, suspended in specializedmethylcellulose-based medium, and cultured for either 2 or 12 days toassess levels of clonogenic progenitors at the colony-formingunit-erythroid (CFU-E) and burst forming unit-erythroid (BFU-E) stages,respectively. Methylcellulose-based medium for BFU-E determination(MethoCult M3434, Stem Cell Technologies) included recombinant murinestem cell factor, interleukin-3, and interleukin-6, which were notpresent in methylcellulose medium for CFU-E determination (MethoCultM3334, Stem Cell Technologies), while both media containederythropoietin, among other constituents. For both BFU-E and CFU-E, thenumber of colonies were determined in duplicate culture plates derivedfrom each tissue sample, and statistical analysis of the results wasbased on the number of mice per treatment group.

Spleen-derived cultures from mice treated with ActRIIB(L79D 25-131)-hFchad twice the number of CFU-E colonies as did corresponding culturesfrom control mice (P≦0.05), whereas the number of BFU-E colonies did notdiffer significantly with treatment in vivo. The number of CFU-E orBFU-E colonies from bone marrow cultures also did not differsignificantly with treatment. As expected, increased numbers of CFU-Ecolonies in spleen-derived cultures were accompanied by highlysignificant (P≦0.001) changes in red blood cell level (11.6% increase),hemoglobin concentration (12% increase), and hematocrit level (11.6%increase) at euthanasia in mice treated with ActRIIB(L79D 25-131)-hFccompared to controls. These results indicate that in vivo administrationof a GDF Trap with truncated ActRIIB extracellular domain can stimulateproliferation of erythroid progenitors as part of its overall effect toincrease red blood cell levels.

GDF Trap fusion proteins have been further demonstrated to be effectivein increasing red blood cell levels in various models of anemiaincluding, for example, chemotherapy-induced anemia, nephrectomy-inducedanemia, and in a blood loss anemia. See, e.g., International PatentApplication Publication No. WO 2010/019261.

Example 19 GDF Trap with Truncated ActRIIB Extracellular DomainIncreases Levels of Red Blood Cells in Non-Human Primates

Two GDF Traps, ActRIIB(L79D 20-134)-hFc and ActRIIB(L79D 25-131)-hFc,were evaluated for their ability to stimulate red blood cell productionin cynomolgus monkey. Monkeys were treated subcutaneously with GDF Trap(10 mg/kg; n=4 males/4 females), or vehicle (n=2 males/2 females) onDays 1 and 8. Blood samples were collected on Days 1 (pretreatmentbaseline), 3, 8, 15, 29, and 44, and were analyzed for red blood celllevels (FIG. 24), hematocrit (FIG. 25), hemoglobin levels (FIG. 26), andreticulocyte levels (FIG. 27). Vehicle-treated monkeys exhibiteddecreased levels of red blood cells, hematocrit, and hemoglobin at allpost-treatment time points, an expected effect of repeated bloodsampling. In contrast, treatment with ActRIIB(L79D 20-134)-hFc orActRIIB(L79D 25-131)-hFc increased these parameters by the firstpost-treatment time point (Day 3) and maintained them at substantiallyelevated levels for the duration of the study (FIGS. 24-26).Importantly, reticulocyte levels in monkeys treated with ActRIIB(L79D20-134)-hFc or ActRIIB(L79D 25-131)-hFc were substantially increased atDays 8, 15, and 29 compared to vehicle (FIG. 27). This resultdemonstrates that GDF Trap treatment increased production of red bloodcell precursors, resulting in elevated red blood cell levels.

Taken together, these data demonstrate that truncated GDF Traps, as wellas a full-length variants, can be used as selective antagonists of GDF11and potentially related ligands to increase red blood cell formation invivo.

Example 20 GDF Trap Derived from ActRIIB5

Others have reported an alternate, soluble form of ActRIIB (designatedActRIIB5), in which exon 4, including the ActRIIB transmembrane domain,has been replaced by a different C-terminal sequence. See, e.g., WO2007/053775.

The sequence of native human ActRIIB5 without its leader is as follows:

(SEQ ID NO: 49) GRGEAETRECIYYNANWELERTNQSGLERCEGEQDKRLHCYASWRNSSGTIELVKKGCWLDDFNCYDRQECVATEENPQVYFCCCEGNFCNERFTHLPEAGGPEGPWASTTIPSGGPEATAAAGDQGSGALWLCLEGPAHE

An leucine-to-aspartate substitution, or other acidic substitutions, maybe performed at native position 79 (underlined) as described toconstruct the variant ActRIIB5(L79D), which has the following sequence:

(SEQ ID NO: 50) GRGEAETRECIYYNANWELERTNQSGLERCEGEQDKRLHCYASWRNSSGTIELVKKGCWDDDFNCYDRQECVATEENPQVYFCCCEGNFCNERFTHLPEAGGPEGPWASTTIPSGGPEATAAAGDQGSGALWLCLEGPAHE

This variant may be connected to human Fc (double underline) with a TGGGlinker (SEQ ID NO: 53) (single underline) to generate a humanActRIIB5(L79D)-hFc fusion protein with the following sequence:

(SEQ ID NO: 51) GRGEAETRECIYYNANWELERTNQSGLERCEGEQDKRLHCYASWRNSSGTIELVKKGCWDDDFNCYDRQECVATEENPQVYFCCCEGNFCNERFTHLPEAGGPEGPWASTTIPSGGPEATAAAGDQGSGALWLCLEGPAHETGGG THTCPPCPAPELLGGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSHEDPEVKFNWYVDGVEVHNAKTKPREEQYNSTYRVVSVLTVLHQDWLNGKEYKCKVSNKALPAPIEKTISKAKGQPREPQVYTLPPSREEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQGNVFSCSV MHEALHNHYTQKSLSLSPGK.

This construct may be expressed in CHO cells.

Example 21 Effects in Mice of Combined Treatment with EPO and a GDF Trapwith a Truncated ActRIIB Extracellular Domain

EPO induces formation of red blood cells by increasing the proliferationof erythroid precursors, whereas GDF Traps could potentially affectformation of red blood cells in ways that complement or enhance EPO'seffects. Therefore, Applicants investigated the effect of combinedtreatment with EPO and ActRIIB(L79D 25-131)-hFc on erythropoieticparameters. Male C57BL/6 mice (9 weeks old) were given a single i.p.injection of recombinant human EPO alone (epoetin alfa, 1800 units/kg),ActRIIB(L79D 25-131)-hFc alone (10 mg/kg), both EPO and ActRIIB(L79D25-131)-hFc, or vehicle (Tris-buffered saline). Mice were euthanized 72h after dosing for collection of blood, spleens, and femurs.

Spleens and femurs were processed to obtain erythroid precursor cellsfor flow cytometric analysis. After removal, the spleen was minced inIscove's modified Dulbecco's medium containing 5% fetal bovine serum andmechanically dissociated by pushing through a 70-μm cell strainer withthe plunger from a sterile 1-mL syringe. Femurs were cleaned of anyresidual muscle or connective tissue and ends were trimmed to permitcollection of marrow by flushing the remaining shaft with Iscove'smodified Dulbecco's medium containing 5% fetal bovine serum through a21-gauge needle connected to a 3-mL syringe. Cell suspensions werecentrifuged (2000 rpm for 10 min) and the cell pellets resuspended inPBS containing 5% fetal bovine serum. Cells (10⁶) from each tissue wereincubated with anti-mouse IgG to block nonspecific binding, thenincubated with fluorescently labeled antibodies against mousecell-surface markers CD71 (transferrin receptor) and Ter119 (an antigenassociated with cell-surface glycophorin A), washed, and analyzed byflow cytrometry. Dead cells in the samples were excluded from analysisby counterstaining with propidium iodide. Erythroid differentiation inspleen or bone marrow was assessed by the degree of CD71 labeling, whichdecreases over the course of differentiation, and Ter119 labeling, whichis increased during terminal erythroid differentiation beginning withthe proerythroblast stage (Socolovsky et al., 2001, Blood 98:3261-3273;Ying et al., 2006, Blood 108:123-133). Thus, flow cytometry was used todetermine the number of proerythroblasts (CD71^(high)Ter119^(low)),basophilic erythroblasts (CD71^(high)Ter119^(high)),polychromatophilic+orthochromatophilic erythroblasts(CD71^(med)Ter119^(high)), and late orthochromatophilicerythroblasts+reticulocytes (CD71^(low)Ter119^(high)), as described.

Combined treatment with EPO and ActRIIB(L79D 25-131)-hFc led to asurprisingly vigorous increase in red blood cells. In the 72-h timeframe of this experiment, neither EPO nor ActRIIB(L79D 25-131)-hFc aloneincreased hematocrit significantly compared to vehicle, whereas combinedtreatment with the two agents led to a nearly 25% increase in hematocritthat was unexpectedly synergistic, i.e., greater than the sum of theirseparate effects (FIG. 28). Synergy of this type is generally consideredevidence that individual agents are acting through different cellularmechanisms. Similar results were also observed for hemoglobinconcentrations (FIG. 29) and red blood cell concentrations (FIG. 30),each of which was also increased synergistically by combined treatment.

Analysis of erythroid precursor levels revealed a more complex pattern.In the mouse, the spleen is considered the primary organ responsible forinducible (“stress”) erythropoiesis. Flow cytometric analysis of splenictissue at 72 h revealed that EPO markedly altered the erythropoieticprecursor profile compared to vehicle, increasing the number ofbasophilic erythroblasts by more than 170% at the expense of lateprecursors (late orthochromatophilic erythroblasts+reticulocytes), whichdecreased by more than one third (FIG. 31). Importantly, combinedtreatment increased basophilic erythroblasts significantly compared tovehicle, but to a lesser extent than EPO alone, while supportingundiminished maturation of late-stage precursors (FIG. 31). Thus,combined treatment with EPO and ActRIIB(L79D 25-131)-hFc increasederythropoiesis through a balanced enhancement of precursor proliferationand maturation. In contrast to spleen, the precursor cell profile inbone marrow after combined treatment did not differ appreciably fromthat after EPO alone. Applicants predict from the splenic precursorprofile that combined treatment would lead to increased reticulocytelevels and would be accompanied by sustained elevation of mature redblood cell levels, if the experiment were extended beyond 72 h.

Taken together, these findings demonstrate that a GDF Trap with atruncated ActRIIB extracellular domain can be administered incombination with EPO to synergistically increase red blood cellformation in vivo. Acting through a complementary but undefinedmechanism, a GDF trap can moderate the strong proliferative effect of anEPO receptor activator alone and still permit target levels of red bloodcells to be attained with lower doses of an EPO receptor activator,thereby avoiding potential adverse effects or other problems associatedwith higher levels of EPO receptor activation.

Example 22 Effect of GDF Trap with a Truncated ActRIIB ExtracellularDomain on RBC Levels and Morphology in a Mouse Model of β-Thalassemia

In thalassemia syndromes, which represent the most common causes ofineffective erythropoiesis, imbalances in the expression of α-andβ-globin chains result in anemia due to increased apoptosis duringerythroblast maturation. RBC transfusion is currently a key maintenancetherapy in thalassemia but over time causes potentially lethal ironaccumulation in certain tissues (Tanno et al, 2010, Adv Hematol2010:358283). For example, heart disease associated with iron overloadcan account for 50% of mortality in patients with thalassemia major(Borgna-Pignatti et al, 2005, Ann NY Acad Sci 1054:40-47). Importantly,endogenous EPO levels are typically elevated and contribute to diseaseetiology in thalassemia syndromes as well as other disorders ofineffective erythropoiesis; therefore, therapeutic use of recombinantEPO may be inappropriate. Thus, there is the need for alternativetherapies for thalassemia and other disorders of ineffectiveerythropoiesis that would increase RBC levels without the iron overloadthat accompanies chronic transfusions.

Applicants investigated the effect of ActRIIB(L79D 25-131)-mFc on RBCformation in a mouse model of β-thalassemia intermedia in which theentire coding region of the β-major globin coding gene has been deleted.Mice homozygous for this Hbb^(th-1) allele exhibit a hypochromic,micocytic anemia with inclusion bodies in a high proportion ofcirculating RBCs (Skow et al, 1983, Cell 1043:1043-1052). In apreliminary experiment, Hbb^(−/−) β-thalassemic mice(C57BL/6J-Hbb^(d3th)/J) at 2-5 months of age were randomly assigned toreceive ActRIIB(L79D 25-131)-mFc (10 mg/kg) or vehicle (Tris-bufferedsaline) by subcutaneous injection twice-weekly. Wildtype littermatesdosed with vehicle served as additional controls. Blood samples (100 μl)were collected by cheek bleed before the onset of dosing and at regularintervals thereafter for CBC analysis. Characterization of hematologicparameters at baseline confirmed that Hbb^(−/−) β-thalassemic mice wereseverely anemic (FIGS. 32A-C), and treatment of Hbb^(−/−) mice withActRIIB(L79D 25-131)-mFc for 4 weeks increased RBC number markedlycompared with vehicle-treated Hbb^(−/−) mice, thereby reducing theanemia observed in this model by half (FIG. 33). Treatment-associatedincreases in hematocrit and hemoglobin concentration were also seen.Importantly, treatment of Hbb^(−/−) mice with ActRIIB(L79D 25-131)-mFcalso resulted in improved RBC morphology and reduced hemolysis anderythrocytic debris compared to vehicle-treated Hbb^(−/−) mice (FIG.34), thus indicating a fundamental improvement in erythropoiesis. Hence,a GDF Trap polypeptide with truncated ActRIIB extracellular domain canprovide therapeutic benefit for anemia in a murine model ofβ-thalassemia by increasing both RBC number and morphology. By promotingerythroblast maturation while reducing anemia, GDF Trap polypeptides cantreat ineffective erythropoiesis. Unlike transfusions, which areinherently a source of exogenous iron, a GDF Trap polypeptide can raiseRBC levels by promoting use of endogenous iron stores viaerythropoiesis, thereby avoiding iron overloading and its negativeconsequences.

Example 23 Effect of a GDF Trap with Truncated ActRIIB ExtracellularDomain on EPO Levels, Splenomegaly, Bone Density, and Iron Overload in aMouse Model of β-Thalassemia

Hypoxia associated with ineffective erythropoiesis causes elevated EPOlevels that can drive massive expansion of erythroblasts both within andoutside the bone marrow, leading to splenomegaly (spleen enlargement),erythroblast-induced bone pathology, and tissue iron overload, even inthe absence of therapeutic RBC transfusions. Untreated iron overloadleads to tissue iron deposition, multiple organ dysfunction, andpremature mortality (Borgna-Pignatti et al., 2005, Ann NY Acad Sci1054:40-47; Borgna-Pignatti et al., 2011, Expert Rev Hematol 4:353-366),most often due to cardiomyopathy in severe forms of thalassemia(Lekawanvijit et al., 2009, Can J Cardiol 25:213-218). By increasingerythropoietic effectiveness, a GDF Trap polypeptide may alleviate notonly the underlying anemia and elevated EPO levels but also theassociated complications of splenomegaly, bone pathology, and ironoverload.

Applicants investigated effects of a GDF Trap polypeptide on theseparameters in the same mouse model of β-thalassemia intermedia studiedin Example 21. Hbb^(−/−) β-thalassemic mice (C57BL/6J-Hbb^(d3th)/J) at 3months of age were randomly assigned to receive ActRIIB(L79D 25-131)-mFc(1 mg/kg, n=7) or vehicle (Tris-buffered saline, n=7) by subcutaneousinjection twice weekly for 2 months. Wildtype littermates dosed withvehicle (n=13) served as additional controls. Blood samples (100 μl)were collected at study termination for CBC analysis. At studytermination, bone mineral density was determined by dual energy x-rayabsorptiometry (DEXA), serum EPO levels were determined by ELISA,reactive oxygen species (ROS) were quantitated with2′,7′-dichlorodihydrofluorescein diacetate and flow cytometry (Suraganiet al., 2012, Blood 119:5276-5284), and hepcidin mRNA levels weredetermined by quantitative polymerase chain reaction.

This GDF Trap polypeptide exerted multiple hematologic effectsconsistent with alleviation of ineffective erythropoiesis. Treatment ofHbb^(−/−) mice with ActRIIB(L79D 25-131)-mFc for 2 months increased RBCcounts by 25% compared with vehicle-dosed Hbb^(−/−) mice (FIG. 35). InHbb^(−/−) mice, ActRIIB(L79D 25-131)-mFc treatment also increasedhemoglobin concentration and hematocrit significantly at 2 monthscompared to vehicle controls. These changes were accompanied by reducedlevels of circulating reticulocytes (31.3±2.3% vs. 44.8±5.0% forHbb^(−/−) mice treated with ActRIIB(L79D 25-131)-mFc or vehicle,respectively), which is consistent with alleviation of anemia. As inExample 21, treatment of Hbb^(−/−) mice with ActRIIB(L79D 25-131)-mFcresulted in improved RBC morphology and reduced erythrocytic debriscompared to vehicle-dosed Hbb^(−/−) mice. Compared to healthyindividuals, patients with thalassemia exhibit an increased rate of RBCdestruction and elevated serum levels of bilirubin, which is a productof heme catabolism and marker of hemolysis (Orten, 1971, Ann Clin LabSci 1:113-124). In Hbb^(−/−) mice, treatment with ActRIIB(L79D25-131)-mFc reduced serum bilirubin levels at 2 months by nearly halfcompared to vehicle (FIG. 36), thereby providing evidence thatActRIIB(L79D 25-131)-mFc can unexpectedly improve thestructural/functional integrity of mature RBCs as it promotes RBCformation. Importantly, treatment of Hbb^(−/−) mice with ActRIIB(L79D25-131)-mFc reduced serum EPO levels at 2 months by more than 60%compared to vehicle in the same model (FIG. 37). Since elevated EPOlevels are a hallmark of ineffective erythropoiesis in β-thalassemia,the reduction of such levels here is strong evidence that ActRIIB(L79D25-131)-mFc alleviates ineffective erythropoiesis itself, not just theanemia it causes, in this murine model of thalassemia.

This GDF Trap polypeptide also produced beneficial changes in endpointsrepresenting major complications of ineffective erythropoiesis. Inthalassemia patients, both splenomegaly and bone deterioration arecaused by EPO-stimulated erythroid hyperplasia and extramedullaryerythropoiesis. In Hbb^(−/−) mice, treatment with ActRIIB(L79D25-131)-mFc for 2 months reduced spleen weight significantly compared tovehicle (FIGS. 38A and 38B) and fully restored bone mineral density towildtype values (FIG. 39). Iron homeostasis was also improvedsignificantly by treatment with this GDF Trap polypeptide. Serum ironconsists of both unbound (free) iron and iron bound to apotransferin(forming transferin), a specialized protein for transporting elementaliron in the circulation. Serum iron constitutes a relatively small andlabile component of total body iron, whereas serum levels of ferritin,another form of iron storage found mainly intracellularly, represent alarger and less labile component. A third measure of iron load istransferin saturation, the degree to which the iron binding capacity oftransferin is occupied. In Hbb^(−/−) mice, ActRIIB(L79D 25-131)-mFctreatment for 2 months reduced each of these indicators of iron overloadsignificantly compared to vehicle (FIGS. 40A-C). In addition to itseffects on these diverse parameters of iron homeostasis, ActRIIB(L79D25-131)-mFc normalized tissue iron overload in Hbb^(−/−) mice asdetermined by histochemical analysis in spleen, liver, and kidney (FIG.41). Moreover, this GDF Trap polypeptide exerted a beneficial effect onexpression of hepcidin, a hepatic protein considered to be the masterregulator of iron homeostasis (Gantz, 2011, Blood 117:4425-4433), whoselevels vary inversely with dietary iron uptake. Treatment withActRIIB(L79D 25-131)-mFc reversed the abnormally low expression ofhepcidin in liver of Hbb^(−/−) mice (FIG. 42). Finally, another studywith similar design was performed to determine the effect of this GDFTrap on reactive oxygen species (ROS), which are thought to mediate manyof the toxic effects of iron overload (Rund et al., 2005, N Engl J Med353:1135-1146). In 3-month-old Hbb^(−/−) mice, treatment withActRIIB(L79D 25-131)-mFc at 1 mg/kg twice weekly for 2 months nearlynormalized ROS levels (FIG. 43) and would therefore be predicted togreatly reduce the tissue damage mediated by ROS in thalassemia andother diseases characterized by ineffective erythropoiesis.

Together, the above findings demonstrate that GDF Trap polypeptides cantreat ineffective erythropoiesis, including anemia and elevated EPOlevels, as well as complications such as splenomegaly,erythroblast-induced bone pathology, and iron overload, and theirattendant pathologies. With splenomegaly, such pathologies includethoracic or abdominal pain and reticuloendothelial hyperplasia.Extramedullary hematopoiesis can occur not only in the spleen butpotentially in other tissues in the form of extramedullary hematopoieticpseudotumors (Musallam et al., 2012, Cold Spring Harb Perspect Med2:a013482). With erythroblast-induced bone pathology, attendantpathologies include low bone mineral density, osteoporosis, and bonepain (Haidar et al., 2011, Bone 48:425-432). With iron overload,attendant pathologies include hepcidin suppression and hyperabsorptionof dietary iron (Musallam et al., 2012, Blood Rev 26(Suppl 1):S16-S19),multiple endocrinopathies and liver fibrosis/cirrhosis (Galanello etal., 2010, Orphanet J Rare Dis 5:11), and iron-overload cardiomyopathy(Lekawanvijit et al., 2009, Can J Cardiol 25:213-218). In contrast toexisting therapies for ineffective erythropoiesis, GDF Trap polypeptidessuch as ActRIIB(L79D 25-131)-mFc are able to reduce iron overloading inmurine models while concurrently increasing RBC levels. This novelcapability distinguishes GDF Trap polypeptides from blood transfusions,which inherently burden the body with exogenous iron in the course oftreating anemia and do so without alleviating the underlying conditionof ineffective erythropoiesis.

Example 24 GDF Trap Increases Hemoglobin Levels and SubstantiallyResolves a Cutaneous Ulcer in a Thalassemia Patient

A clinical study was designed to treat thalassemia patients(β-thalassemia intermedia and major patients) with multiple does ofActRIIB(L79D 25-131)-hFc. The study comprised both non-transfusiondependent patients (<4 units/8 weeks, hemoglobin <10 g/dL) andtransfusion (blood) dependent patients (≧4 units/8 weeks confirmed over6 months). Patients were divided into one of four treatment groups: i)administration of 0.2 mg/kg ActRIIB(L79D 25-131)-hFc by subcutaneousinjection every three weeks; ii) administration of 0.4 mg/kgActRIIB(L79D 25-131)-hFc by subcutaneous injection every three weeks;iii) administration of 0.6 mg/kg ActRIIB(L79D 25-131)-hFc bysubcutaneous injection every three weeks: and iv) administration of 0.8mg/kg ActRIIB(L79D 25-131)-hFc by subcutaneous injection every threeweeks. Over the course of three months of treatment, patients wereobserved to have significant, dose-dependent increases in hemoglobinlevels. Furthermore, ActRIIB(L79D 25-131)-hFc treatment was effective atdecreasing transfusion dependency, i.e., all transfusion dependentpatients experienced a >50% reduction in transfusion burden during thecourse of the study.

One patient with a baseline hemoglobin level of approximately 9.2 g/dLreceived 4 doses of ActRIIB(L79D 25-131)-hFc at the 0.4 mg/kg level,resulting in a hemoglobin level of approximately 10.6 g/dL after threemonths of treatment. The patient's thalassemia was (3-thalassemiaintermedia, and the patient was non-transfusion dependent. Forapproximately three years prior to this study, this patient had beenafflicted with recurrent skin ulcers in the lower limbs. Such ulcers arecommon cutaneous complications of thalassemia. See, e.g., Rassi et al.(2008) Pediatric Annals 37(5): 322-328. Prior to ActRIIB(L79D25-131)-hFc treatment, this patient was diagnosed with a leg ulcer.Ulcer healing was observed two weeks after administration of the firstActRIIB(L79D 25-131)-hFc dose. After six weeks of ActRIIB(L79D25-131)-hFc treatment, the leg ulcer was determined to be substantiallyresolved. A second non-transfusion dependent patient began the studywith a leg ulcer. The leg ulcer was substantially resolved aftertreatment with several doses of ActRIIB(L79D 25-131)-hFc at 1.25 mg/kg.In addition, a transfusion-dependent patient began the study with anulcer on the left ankle. After five doses of ActRIIB(L79D 25-131)-hFc at1.0 mg/kg the ulcer was substantially resolved and remained so for theduration of the study. Accordingly, ActRIIB(L79D 25-131)-hFc can be usedto effectively treat ulcers that manifest in non-transfusion andtransfusion dependent thalassemia patients.

Accordingly, these data demonstrate that ActRIIB(L79D 25-131)-hFctreatment is effective in increasing hemoglobin levels and can be usedto reduced transfusion dependency in human thalassemia patients. Inaddition to the positive effects on the anemia aspects of the disease,the significant improvement in healing of the leg ulcers indicates thatActRIIB(L79D 25-131)-hFc can be used to effectively treat othernon-anemia complications of thalassemia, which is consistent with thedata from the mouse model of β-thalassemia described above.

Example 25 GDF Trap Increases Red Blood Cell Levels and Improves RedBlood Cell Morphology in Sickle-Cell Disease Model

Applicants investigated the effect of ActRIIB(L79D 25-131)-mFc on redblood cell (RBC) formation in a mouse model of sickle-cell disease (SCD)in which the mouse hemoglobin genes (α/α and β/β) have been replacedwith the human sickle hemoglobin genes (α/α, γ/γ, and β^(S)/β^(S)). Micehomozygous for the human β^(S) allele exhibit the major features (e.g.,sever hemolytic anemia, irreversibly sickled red cells, vascular (vaso)occlusion, and multi-organ pathology) found in humans with SCD. See,e.g., Wu et al., (2006) Blood, 108(4): 1183-1188; Ryan et al. (1997)Science 278: 873-876.

SCD mice (β^(S)/β^(S)) at 3 months of age were randomly assigned toreceive ActRIIB(L79D 25-131)-mFc (1 mg/kg) or vehicle [Tris-bufferedsaline (TBS)] by subcutaneous injections twice weekly. Non-symptomaticcompound heterozygote (β/β^(S)) litermates dosed with vehicle served asadditional controls (Wt animals). At baseline, SCD mice had reduced RBClevels (−28%, P<0.01) and hemoglobin levels (−14.5%, P<0.05) andincreased reticulocyte levels (+50%, P<0.001) compared to the compoundheterozygote mice, demonstrating that the SCD mice were severely anemic.

Following one month of treatment, subjects were assessed for changes invarious red blood cell parameters. Treatment of SCD mice withActRIIB(L79D 25-131)-mFc for 4 weeks increased RBC levels markedly(+15.2%, p<0.01) compared to vehicle-treated SCD mice, thereby reducingthe anemia observed in this model (FIGS. 44 and 45). ActRIIB(L79D25-131)-mFc treatment-associated increases in hematocrit and hemoglobinconcentrations were also observed (FIG. 45) as well as significantdecreases in mean corpuscular volume, RDC distribution width,reticulocyte numbers, and reactive oxygen species (FIG. 46), which isall consistent with improved red blood cell half-life. Surprisingly,treatment of SCD mice with ActRIIB(L79D 25-131)-mFc for 6 weeks resultedin a substantial decrease in phosphatidylserine (PS) exposure inperipheral blood cells (−14%, P=0.08), as determined by scramblaseenzyme assay and annexin-V assay, indicating a trend toward improvedmembrane phospholipid asymmetry compared to vehicle-treated subjects.

Following three months of treatment, subjects were observed to haveimprovements in additional blood chemistry parameters. In particular,treatment of SCD mice with ActRIIB(L79D 25-131)-mFc for 12 weekssignificantly decreased bilirubin (total) levels (−17.0%, p<0.05), bloodurea nitrogen levels (−19.2%, p<0.05), and cell free hemoglobin (−30.7%.p=0.06) compared to vehicle-treated SCD mice. These data indicate thatGDF Trap-treated subjects have decreased levels of red blood cellhemolysis in comparison to vehicle-treated subjects, which is consistentwith the observed increase of red blood cell levels observed as early asone month following the start of ActRIIB(L79D 25-131)-mFc therapy.Annexin-V assays demonstrated a significant decrease inphosphatidylserine (PS) exposure in peripheral blood cells (−13.4%,p=0.06) after three months of therapy in comparison to vehicle-treatedsubjects. Moreover, blood smears performed after three months oftreatment showed fewer irreversibly sickle-formed red blood cells inActRIIB(L79D 25-131)-mFc-treated mice (−66.5%, p<0.0001; enumerated fromapproximately 2000 cells per group) in comparison to mice treated withvehicle alone. These data indicate a qualitative improvement in redblood cell morphology following ActRIIB(L79D 25-131)-mFc treatment,which is consistent with the scramblase enzyme assay and annexin-V assaydata obtained after one and three months of ActRIIB(L79D 25-131)-mFctreatment. Furthermore, treatment of SCD mice with the GDF Trap forthree months also resulted in a significant decrease in spleen weight(−20.5%, p<0.05) in comparison to vehicle-treated SCD mice. These dataindicate that ActRIIB(L79D 25-131)-mFc may be useful in the treatment ofother complications associated with SCD including, for example, splenicsequestration of red blood cells, which can result in splenicsequestration crisis and/or spenomegaly.

Together, these data indicate that a GDF Trap comprising a truncatedActRIIB extracellular domain can provide various therapeutic benefits ina murine model of SCD. In addition to increasing RBC levels andimproving various blood parameters, the data demonstrate improvement inRBC morphology. This observed improvement in RBC morphology indicatesthat GDF Trap treatment may be used to treat or prevent various othercomplications of SCD (e.g., complications arising from vaso-occlusion)in addition to anemia. This is further supported by the observeddecrease in spleen size in ActRIIB(L79D 25-131)-mFc-treated subjects.

Accordingly, the data presented herein suggest that GDF Trappolypeptides can be used to treat a variety of complications ofsickle-cell disease. Unlike red blood cell transfusions, which areinherently a source of exogenous iron, a GDF Trap polypeptide can raiseRBC levels by promoting use of endogenous iron stores via erythropoiesisand thus avoid iron overloading and its negative consequences.

As observed in thalassemia patients, skin ulcers are one of the mostcommon cutaneous complications of sickle-cell disease. See, e.g., Keastet al. (2004) Ostomy Wound Manage., 50(10): 64-70; Trent et al. (2004)Adv Skin Wound Care, 17(8): 410-416; and J. R. Eckman (1996) HematolOncol Clin North Am., 10(6): 1333-1344. The underlying mechanism forulcer formation in anemic patients has not been completely defined.However, it is believed that multiple complications of anemia contributeto ulcer development including, for example, ischemia, decreased nitricoxide bioavailability, vascular obstruction (particularly in the case ofsickle-cell anemia and thalassemia), thrombosis, high levels ofcirculating reticulocytes, and hypoxia. Id. As discussed above, theinstant disclosure demonstrates that ActRIIB(L79D 25-131)-Fc treatmentalleviates many of these sickle-cell disease associated conditions.Accordingly, the data disclosed herein suggests that, as was observed inthalassemia patients described above, ActRII antagonists may be used inthe treatment and prevention of ulcers in patients that have sickle-celldisease.

INCORPORATION BY REFERENCE

All publications and patents mentioned herein are hereby incorporated byreference in their entirety as if each individual publication or patentwas specifically and individually indicated to be incorporated byreference.

While specific embodiments of the subject matter have been discussed,the above specification is illustrative and not restrictive. Manyvariations will become apparent to those skilled in the art upon reviewof this specification and the claims below. The full scope of theinvention should be determined by reference to the claims, along withtheir full scope of equivalents, and the specification, along with suchvariations.

I claim:
 1. A method for treating a cutaneous ulcer in a subject thathas thalassemia syndrome, comprising administering to the subject apolypeptide comprising an amino acid sequence that is at least 85%identical to the sequence of amino acids 29-109 of SEQ ID NO: 1, whereinthe polypeptide comprises and acidic amino acid at the positioncorresponding to position 79 of SEQ ID NO:
 1. 2. The method of claim 1,wherein the polypeptide comprises an amino acid sequence that is atleast 90% identical to the sequence of amino acids 29-109 of SEQ IDNO:1, wherein the polypeptide comprises an acidic amino acid at theposition corresponding to position 79 of SEQ ID NO:
 1. 3. The method ofclaim 1, wherein the polypeptide is a fusion protein further comprisingan immunoglobulin Fc domain.
 4. The method of claim 3, wherein thefusion protein further comprises a linker domain positioned between thepolypeptide and the immunoglobulin Fc domain.
 5. The method of claim 1,wherein the polypeptide comprises one or more amino acid modificationsselected from: a glycosylated amino acid, a PEGylated amino acid, afarnesylated amino acid, an acetylated amino acid, a biotinylated aminoacid, and an amino acid conjugated to a lipid moiety.
 6. The method ofclaim 1, wherein the polypeptide comprises an amino acid sequence thatis 95% identical to amino acids 29-109 of SEQ ID NO: 1, and wherein thepolypeptide comprises an acidic amino acid at the position correspondingto position 79 of SEQ ID NO:
 1. 7. The method of claim 1, wherein thepolypeptide comprises amino acids 29-109 of SEQ ID NO: 1, and whereinthe polypeptide comprises an acidic amino acid at the positioncorresponding to position 79 of SEQ ID NO:
 1. 8. The method of claim 1,wherein the polypeptide comprises an amino acid sequence that is atleast 85% identical to the sequence of amino acids 25-131 of SEQ ID NO:1, and wherein the polypeptide comprises an acidic amino acid at theposition corresponding to position 79 of SEQ ID NO:
 1. 9. The method ofclaim 1, wherein the polypeptide comprises an amino acid sequence thatis at least 90% identical to the sequence of amino acids 25-131 of SEQID NO: 1, and wherein the polypeptide comprises an acidic amino acid atthe position corresponding to position 79 of SEQ ID NO:
 1. 10. Themethod of claim 1, wherein the polypeptide comprises an amino acidsequence that is at least 95% identical to the sequence of amino acids25-131 of SEQ ID NO: 1, and wherein the polypeptide comprises an acidicamino acid at the position corresponding to position 79 of SEQ ID NO: 1.11. The method of claim 1, wherein the polypeptide comprises amino acids25-131 of SEQ ID NO: 1, and wherein the polypeptide comprises an acidicamino acid at the position corresponding to position 79 of SEQ ID NO: 1.12. The method of claim 1, wherein the polypeptide comprises an aminoacid sequence that is at least 85% identical to SEQ ID NO: 44, andwherein the polypeptide comprises an acidic amino acid at the positioncorresponding to position 79 of SEQ ID NO:
 1. 13. The method of claim 1,wherein the polypeptide comprises an amino acid sequence that is atleast 90% identical to SEQ ID NO: 44, and wherein the polypeptidecomprises an acidic amino acid at the position corresponding to position79 of SEQ ID NO:
 1. 14. The method of claim 1, wherein the polypeptidecomprises an amino acid sequence that is at least 95% identical to SEQID NO: 44, and wherein the polypeptide comprises an acidic amino acid atthe position corresponding to position 79 of SEQ ID NO:
 1. 15. Themethod of claim 1, wherein the polypeptide comprises the amino acidsequence of SEQ ID NO: 44, and wherein the polypeptide comprises anacidic amino acid at the position corresponding to position 79of SEQ IDNO:
 1. 16. The method of claim 1, wherein the polypeptide inhibitssignaling by GDF8 in a cell-based assay.
 17. The method of claim 1,wherein the polypeptide inhibits signaling by GDF11 in a cell-basedassay.
 18. The method of claim 1, wherein the amino acid at the positioncorresponding to position 79 of SEQ ID NO: 1 is an aspartic acid. 19.The method of claim 1, wherein the amino acid at the positioncorresponding to position 79 of SEQ ID NO:1 is a glutamic acid.
 20. Themethod of claim 1, wherein the patient has a β-thalassemia syndrome. 21.The method of claim 20, wherein the patient has β-thalassemia minor. 22.The method of claim 20, wherein the patient has β-thalassemiaintermedia.
 23. The method of claim 20, wherein the patient hasβ-thalassemia major.
 24. The method of claim 1, wherein the patient hasalpha-thalassemia syndrome.
 25. The method of claim 1, wherein thepolypeptide binds GDF8.
 26. The method of claim 1, wherein thepolypeptide binds GDF11.